World Hospitals and Health Services - International Hospital ...

2011 Volume 47 Number 3
www.ihf-fih.org
World Hospitals and Health Services
The Official Journal of the International Hospital Federation
Editorial
Special feature: the evolving role of hospitals in
health systems
The role of hospitals within the framework of the
renewed Primary Health Care (PHC) strategy
The role of the hospital in the changing landscape
of UAE health care: a focus on Dubai
Hospitals of the future
The underlying theories of health care reform in
the United States – Strategy implications for
hospitals
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Effects of payment mechanisms on hospital
behaviours in Brazil: evidence from a multi-payer
and multi-payment system
Hospitals and delivery systems: the need for
change
Better than a crystal ball? Using simulation to
foresee emerging issues in the Australian
Healthcare System
Reshuffling the pack in the Swiss hospital market
The evolving roles of hospitals in health systems:
the Lagos, Nigeria example
The Lesotho Hospital PPP experience: catalyst for
integrated service delivery

Contents
Contents volume 47 number 3
Special feature: the evolving role of hospitals in health systems
03 Editorial Eric de Roodenbeke and Alexander S Preker
06 The role of hospitals within the framework of the renewed Primary Health Care (PHC)
strategy Denis Porignon, Reynaldo Holder, Olga Maslovskaia, Tephany
Griffith, Avril Ogrodnick and Wim Van Lerberghe
11 The role of the hospital in the changing landscape of UAE health care: a focus
on Dubai
Amer Ahmad Sharif and Iain Blair
15 Hospitals of the future
Richard J Umbdenstock, Maulik S Joshi and Jill Seidman
20 The underlying theories of health care reform in the United States – Strategy
implications for hospitals
Daniel B McLaughlin and Jack Militello
24 Effects of payment mechanisms on hospital behaviours in Brazil: evidence from a
multi-payer and multi-payment system
Bernard F Couttolenc and Gerard M La Forgia
28 Hospitals and delivery systems: the need for change
Nigel Edwards
31 Better than a crystal ball? Using simulation to foresee emerging issues in the
Australian Healthcare System
Patrick Bolton and Prue Power
34 Reshuffling the pack in the Swiss hospital market
Bernard Wegmüller and Martin Bienlein
36 The evolving roles of hospitals in health systems: the Lagos – Nigeria example
example
Dr Rafiat Olufunmilayo Olatunji and Dr Olufemi M Omololu
39 The Lesotho Hospital PPP experience: catalyst for integrated service delivery
Carla Faustino Coelho and Catherine Commander O’Farrell
Reference
38 Language abstracts
43 IHF corporate partners
47 Governing Council list
48 Dates for your diary
Editorial Staff
Executive Editor: Eric de Roodenbeke, PhD
Desk Editor: Yohana Dukhan
External Advisory Board
Alexander S Preker Chair of the Advisory Board, World Bank
Michael Borrowitz, Organization for Economic Co-operation
and Development
Jeni Bremner, European Health Management Association
Charles Evans, American College of Healthcare Executives
Pamela Fralick, Canadian Healthcare Association
Abdelmaji Tibouti, UNICEF
Juan Pablo Uribe, Fundación Santa Fe de Bogota
Editorial Committee
Enis Baris, World Bank
Dov Chernichosky, Ben-Gurion University
Bernard Couttelenc, Performa Institute
Nigel Edwards, KPMG, Kings Fund
KeeTaig Jung, Kyung Hee University
Harry McConnell, Griffith University School of Medicine
Louis Rubino, California State University
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World Hospitals and Health Services Vol. 47 No. 3 01

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Editorial
Editorial
ERIC DE ROODENBEKE
CHIEF EXECUTIVE OFFICER, INTERNATIONAL HOSPITAL
FEDERATION
ALEXANDER S PREKER
CHAIR OF THE EXTERNAL ADVISORY BOARD
The hospital of today is a remarkable testimonial to the
scientific advances of the 20th century and man’s ingenuity
in pushing human survival and quality of life to an everexpanding
limit.
Heavy investments over the past 30 years have made the
hospital sector the largest expenditure category of the health
system in most developed and developing countries. Despite
shifts in attention and emphasis toward primary care as a first
point of contact for patients, in most countries, hospitals remain,
in most countries, a critical link to health care, providing both
advanced and basic care for the population. Often, hospitals are
the provider “of last resort” for the poor and critically ill when other
services fail and households run out of money.
In most countries – western and developing – the community
hospital is a cornerstone provider of primary care and other basic
services to the population, fulfilling a role similar to those of
schools, social services, water, sanitation systems and electricity.
And in major urban centers, even in low-income countries, the
university hospital is often a pinnacle of technological splendor –
unsurpassed in other sectors of the economy. It is the future come
true today.
Revered as hospitals are in this context, from a different point of
view, they are also one of the most reviled parts of the health
system. Ministries of Finance or the Treasury, consider the
hospital a “black hole” in their fiscal accounts, a monster with an
insatiable appetite and a chameleon with infinite ability to reinvent
itself in new and costly ways. In developing countries where
resources are often scarce and quality low, a referral to a hospital
may be a “death sentence” – a place of no return.
In most countries – western and
developing – the community hospital
is a cornerstone among the basic
services provided to the population,
like primary care, schools, social
services, water, sanitation systems
and electricity
Whatever the perspective, the hospital is a place that treats
seriously ill patients, has dedicated staff and struggles to make
ends meet in the face of unquenchable demand. They are a place
of great joy at the time of birth and successful recovery from
serious illness. And they are a place of great sorrow at the time of
incurable illness and death.
The authors demonstrate that running a high-performing
hospital is a complicated business requiring strong leadership,
management skill and willingness to be innovative in a changing
world.
The first article, by Denis Porignon, Reynaldo Holder, Olga
Maslovskaia, Tephany Griffith, Avril Ogrodnick, and Wim Van
Lerberghe, sets the scene. Avril emphasizes the need for health
systems integration and continuity of care across levels of care. It
makes it clear to all that hospitals are needed as part of health
system in addition to primary care. When it is time to set up
priorities, the tendency to put in opposition primary care and
referral care are from another age. People will receive good health
care only if the continuum of care works properly.
The article by Amer Ahmad Sharif and Iain Blair describes the
changes that have taken place in the hospital sector of the United
Arab Emirates during the past 40 years and the remarkable
associated improvements in population health. Today their
hospital sector is growing, with a strong input from private sector
investments. The authors emphasize that current and future health
needs of the population are complex, requiring hospitals to adapt
to new and innovative approaches in the balance between
inpatient and ambulatory care. Anticipating such trends and
introducing the needed reforms requires a clear vision for the
future and strong leadership. This story is universal and reflects
the changes that have taken place in the hospital sector in many
developing countries over the past few decades.
Rapid progress and change is not just in the developing world.
Richard Umbdenstock, Maulik Joshi and Jill Seidman describe the
core elements of the recent landmark Affordable Care Act in
United States. They stress that U.S. hospitals and the health
systems more broadly face unprecedented demand to change in
both the near- and longer-term future, due to factors ranging from
demographic changes to increasing reliance on value-based
payment, and to the uncertainty surrounding governmental
World Hospitals and Health Services Vol. 47 No. 3 03

Editorial
reform. They identify four key strategies to deal with the changes
introduced through the reforms: (a) aligning hospitals, physicians,
and other providers across the continuum of care; (b) using
evidenced-based practices to improve quality and patient safety;
(c) improving efficiency through productivity and financial
management; and (d) developing integrated information systems
that will allow providers to better manage both services and clinical
care.
Daniel B. McLaughlin and Jack Militello continue some of these
themes, looking specifically at the changes that are likely to take
place following reforms in payments systems and the new
emerging competitive marketplace in the USA.
Further south, Bernard F. Couttolenc and Gerard M. La Forgia
also describe the important role that payment systems play in
Brazil in providing incentives for improved hospital performance
under a multipayer and multipayment system.
Moving to the other side of the Atlantic, Nigel Edwards describes
the significant pressures confronting hospitals across Europe and
how they are facing the need to change. They are not well
adapted to deal with the current financial crisis and accompanying
challenges. In many cases, the overarching framework is poorly
adapted to deal with change. He highlights that European
hospitals need strong leadership coupled with bold and
imaginative solutions to deal with the challenges they face in the
near future.
Patrick Bolton and Prue Power provide a vivid example of how
modern information technology and modeling can be used to
simulate the results of various proposed reforms in the Australia
context, allowing policy makers and hospital managers to avoid
costly and damaging mistakes, while identifying opportunities for
positive change.
Bernard Wegmuller and Martin Bienlein echo some of these
themes in the context of the reshuffling of the pack in the Swiss
hospital market and complex private multipayer health insurance
system.
Continuing the theme of reassessing the role of hospitals in
modern health systems, Olufemi M. Omololu and Rafiat O. Olatunji
describe the challenges that face the Nigeria hospital sector. They
emphasize the need to include the hospital sector in countries
where the focus on health care reform is often dominated by
vertical disease programs and agendas set by donors rather than
the need for systemic health systems reform. Lagos State in
Nigeria is taking a step in this direction with its new Health Service
Whatever the perspective, the
hospital is a place that treats
seriously ill patients, has
dedicated staff and struggle
making ends meet in the face of
a insurmountable demand
Reform Law, which includes an emphasis on improving the
functioning of hospitals and new innovative approaches.
Carla Faustino Coelho and Catherine Commander O’Farrell
describe one such innovative approach in Lesotho. When faced
with a need to replace its main public hospital, Queen Elizabeth II,
the country decided to design and construct the new 425 bed
public hospital and adjacent primary care clinic through a public
private partnership (PPP) using a private operator under an 18-
year contract. This included the renovation and expansion of three
strategic clinics in the region and the management of all facilities,
equipment and delivery of all clinical services under the health
network. The creation of this PPP health network and the
contracting mechanism has increased accountability for service
quality, shifted the government to a more strategic leadership and
policy-making role. This PPP has become a model for managing
other public sector facilities and providers in Lesotho.
With this special issue, we are sure that you will be able to have
a quick and comprehensive update on the key challenges facing
the hospital sector in the world. In the 37 World Hospital Congress
hosted by Dubai, November 8–10, 2011 the attendees will have
the opportunity to enlarge their perspective on some of the key
subjects presented in this issue. ❏
04 World Hospitals and Health Services Vol. 47 No. 3

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The evolving role of hospitals in health systems
The role of hospitals within the
framework of the renewed Primary
Health Care (PHC) strategy
DENIS PORIGNON
HEALTH POLICY EXPERT, HEALTH SYSTEM POLICY, GOVERNANCE
AND SERVICE DELIVERY DEPARTMENT (HDS), WORLD HEALTH
ORGANIZATION (WHO)
REYNALDO HOLDER, OLGA MASLOVSKAIA, TEPHANY
GRIFFITH, AVRIL OGRODNICK AND WIM VAN LERBERGHE
ABSTRACT: This article summarizes a presentation made at the IHF Leadership Summit held in Chicago, USA in
June 2010, by Denis Porignon from the World Health Organization (WHO) and Reynaldo Holder from the Pan
American Health Organization (PAHO/WHO). It focuses on the role of hospitals within the framework of the
renewed PHC strategy.
PHC renewal
The global commitment to Primary Health Care (PHC) was first
made in 1978 with the Declaration of Alma-Ata. Early attempts at
PHC implementation netted key health and health-related
improvements across multiple sectors. On the whole people
across the world are healthier and live longer than thirty years ago.
A changing world, however, commands a responsibility to adapt
the way health is dealt with. Anticipating and adapting is
necessary because of the transitions: the demographic transition,
the epidemiological transition, but also the transition in demand,
itself fuelled by an expanding middle class with rising expectations.
It is equally necessary because of the evolution ion the supply
side: a different workforce with new contradicts and new
expectations, advancements in technology and knowledge and
growing concerns about costs in a context of globalisation 2 . All
this has led the World Health Organization to revisit the PHC
approach 30 years after Alma Ata, with the 2008 World Health
Report - “Primary Health Care – now more than ever” (Tables 1
and 2). This report signalled a renewed commitment to health for
all, suggesting key policy directions: inclusive governance of the
health sector, so as to build trust and sustainable leadership;
investment in public policy reforms to promote and protect the
health of communities; a move towards universal coverage, to
increase equity in health; and a profound reorientation of health
care delivery, to make health systems people centered, building on
a strong primary care infrastructure.
The conventional model of care focuses disproportionately on
treating acute episodes of disease. It is neither sufficiently
comprehensive nor organised to provide adequate care for
vulnerable populations or persons with chronic diseases. As they
should, hospitals privilege disease-centred care for acute
conditions and complications of chronic disease, but they most
often do this in a setup where the connection with primary care is
ill-conceived or neglected 7 . At the same time, and by default or by
design, hospital outpatient and emergency departments provide a
considerable part of ambulatory care. In doing so they also share
the paradigmatical weakness of much conventional health care
delivery (table 3).
Responding to a new health paradigm requires changes in all
areas of health services, and it is important that health systems are
sufficiently flexible to quickly adapt to new circumstances 3, 4, 5 : the
demographic and epidemiological transition, but also the transition
in demand and in expectation, and the social tensions associated
with globalization. Hospitals are an integral part of all health
systems: as health systems evolve, so does the role of the
hospital. Hospitals will remain central to how people perceive their
health systems and to technical innovation. But they will have to
find a new place within the health care system as the necessary
back-up for primary care, and no longer as the only institution
around which all the rest evolves. Hospitals will have to adapt to
an organization in networks with primary care at the centre. It is
thus important to define the function of hospitals in this context
and elucidate the needs and challenges that hospitals are likely to
face in the future.
The hospital within the health care system
In the future hospitals will no longer be the centre of the health
system or stand alone. They will be part of a network that includes
primary care, specialized out-patient care, and diagnostic services
organized in networks. They will also be more open to the
community and to the other members of the network including
social services. Hospitals should then be able to contribute to
improving health and reducing inequalities, as part of the wider
health system, and should provide a highly valued ‘rescue’
6 World Hospitals and Health Services Vol. 47 No. 3

The evolving role of hospitals in health systems
Table 1: How experience has shifted the focus of the PHC movement
Early attempts at implementing PHC
Extended access to a basic package of health interventions and
essential drugs for the rural poor
Concentration on mother and child health
Focus on a small number of selected diseases, primarily infections
and acute
Improvement of hygiene, water, sanitation and health education
at village level
Simple technology for volunteer, non-professional community
health workers
Primary care as the antithesis of the hospital
PHC is cheap and requires only a modest investment
Current concerns of PHC reforms
Transformation and regulation of existing health systems, aiming for
universal access and socialhealth protection
Dealing with the social health of everyone in the community
A comprehensive response to people’s expectations and needs,
spanning the range of risks and illnesses
Promotion of healthier lifestyles and mitigation of the health effects
of social and environmental hazards
Teams of health workers facilitating access to and appropriate use of
technology and medicines
Primary care as coordinator of a comprehensive response at all levels
PHC is not cheap: it requires considerable investment, but it provides
better value for money than its alternatives
Source: The World Health Report 2008 - Primary health care. Now more than ever. Geneva, World Health Organization, 2008.
Table 2: Transformation of the health paradigm
Old Paradigm
Responsibility for individuals
Emphasis on care of acute episodes of disease
The service providers are essentially equal
Success is measured by the capacity to increase
hospital admissions
The objective of the hospitals is to fill beds
Insurers, hospitals, ambulatory centers,
work separately (Fragmentation)
Management of isolated organizations
Emerging Paradigm
Responsibility for the health of defined populations
Emphasis on care throughout the continuum
Differentiation based on the capacity to provide added value
Success depends on increasing coverage and capacity to maintain people healthy.
The objective of the network is to provide the appropriate care at the appropriate level
Networks of Integrated Delivery Services (IDS)
Management of networks
Source: The World Health Report 2008 - Primary health care. Now more than ever. Geneva, World Health Organization, 2008.
Table 3: Aspects of care that distinguish conventional health care from people-centred primary care
Conventional ambulatory medical care in Disease control programmes People-centred primary care
clinics or outpatints departments
Focus on illness and cure Focus on priority diseases Focus on health needs
Relationship limited to the moment of consultation Relationship limited to programme Enduring personal relationship
implmentation
Episodic curatove care Programmme-defined disease Comprehensive, continuous and
control interventions
person-centred care
Responsibility limited to effective and safe Responsibility for disease-control Responsibility for the health of all in the
advice to the patient at the moment of consultation target among the target population community along the life cycle; repsonsibility
for tackling determinannts of ill-health
Users are consumers of the care they purchase Population groups are targets of People are partners in managing their own
disease-control interventions
health and that of their community
The World Health Report 2008 - Primary health care. Now more than ever. Geneva, World Health Organization, 2008.
World Hospitals and Health Services Vol. 47 No. 3 7

The evolving role of hospitals in health systems
Figure 1: Primary care as a hub of coordination with hospitals’ roles and services
Specialized care
Diabetes
clinic
TB control
centre
Referral for complications
Referral for
muti-drug resistance
Community
mental
health unit
Consultant support
Traffic
accident
Emergency
department
Maternity
Placenta
praevia
Hospital
Hernia
Surgery
Diagnostic services
CT
Scan
Cytology
lab
Diagnostic support
Pap smears
Self-help
group
Liaison
community
health worker
Primary-care team:
continuous, comprehensive
person-centred care
Other
Other
Social service
Training
support
Training centre
Environmental
health lab
Waste disposal
inspection
Specialized prevention services
Cancer
screening centre
Mammography
Gender
violence
Women’s
shelter
Alcoholism
Alcoholics
anonymous
NGOs
Source: The World Health Report 2008 - Primary health care. Now more than ever. Geneva, World Health Organization, 2008.
Improving health information
systems may help hospital
planning and regulation by
improving information-based
decision making
function for life-threatening conditions, and can improve outcomes
from treatment by concentrating technology/expertise where
necessary 9 .
The organization of health services within the PHC framework
will then be based on three tenets:
✚ Hospitals should not be the entry point - relocating the entry
point to the health system from hospitals and specialists to
close-to-client generalist primary-care centres and the like;
✚ Instead, hospitals will function as part of health care networks
to fill the availability gap of complementary referral care by
giving primary-care providers the responsibility for the health of
a defined population, in its entirety;
✚ The role of primary-care providers’ as coordinators of the
inputs of other levels of care should be strengthened by giving
them administrative authority and purchasing power.
The Pan American Health Organization defines a PHC-based
health system as an overarching approach to the organization and
operation of health systems that makes the right to the highest
attainable level of health its main goal while maximizing equity and
solidarity. With the shift in focus of the PHC movement over time,
and under the revised model, implementation of PCH now requires
more commitment and investment, and ultimately will deliver
coordinated and comprehensive care. The expected benefits of
the new PHC strategy are improvements in health outcomes at the
population level, efficiency, access to health services, and equity,
as well as lower costs and increased user satisfaction 1,7 .
Hospital costs are high compared to primary care costs. This
does not mean that hospitals are inefficient; it means that primary
care and hospitals have different roles and responsibilities, and
one should provide care for each case at the most efficient
location where this can be done effectively. This requires a clear
division of labour with provisions to eliminate catastrophic health
expenditure both at primary care and at hospital levels.
In many countries there is an acute need for redesigning
hospitals so that they can meet patient expectations, improve
clinical outcomes and incorporate flexibility. The sustainability of
capital investments should be ensured by investing in high quality
products that have a high value for money. In addition, hospitals
need to invest in their workforce by planning for the future and
expanding their evidence base. Planning the capacity and
infrastructure of a hospital, should be based on needs, service
activity and service volume and not on population growth 3, 14 .
Traditionally, bed capacity ratios are used to determine capacity;
however, this method is proven to be misleading 3, 14 . Improving
health information systems may help hospital planning and
regulation by improving information-based decision making 1 . The
policy directions set by the renewal of PHC carry a lot of potential
to produce health, reduce inequalities and tackle the wasteful
fragmentation of health systems. But they will not happen
spontaneously. The convergence of the equity and health systems
8 World Hospitals and Health Services Vol. 47 No. 3

The evolving role of hospitals in health systems
agendas are mentioned in a number of recently produced reports
including the “World Health Report 2008: Primary Health Care.
Now More Than Ever”, "Strengthening Health Systems to Improve
Health Outcomes: WHO’s Framework for Action”, “Closing the
Gap in a Generation: Health equity through action on the social
determinants of health”, and “The World Health Report 2010:
Health systems financing: the path to universal coverage”. These
reports all emphasize the importance of linking PHC-based health
systems with other determinants of health by incorporating “health
in all policies” and by emphasizing equity, social protection, intersectoriality,
health promotion and participation, human rights and
equality. While incorporating the PHC strategy, it is also important
to understand what people value and want from a health system.
People want to live long and healthy lives; to be treated fairly and
equitably; to have a say in what affects their lives and the lives of
their families; to be regarded as human beings and not just
"cases" in the medical system; to have a reduced risk of diseases;
to have reliable health authorities; and to receive efficient services
and effective medicines and technologies. This has implications
for the future of hospitals. As health systems continue to change
and the PHC approach is implemented, the role of hospitals will
evolve, but they will still remain vital to the health system 15 ). In the
future, hospital functions, healthcare network responsibilities and
an effective continuum of care will be of crucial importance.
Instead of having a hospital-centred health system, a balance
should be achieved between people-centeredness and
technological requirements, between over and under spending
with high risk of error repetition, between the lobby of equipment
and pharmaceutical industry and between social aspects of equity
and inclusiveness and participation. While there are multiple ways
to provide services, the objectives in all contexts should
encourage accessibility, efficiency, quality of care, responsiveness
and fairness in financing. ❏
References
1.
World Health Organization. Primary health care: now more than ever. Geneva, WHO, 2008.
2.
McKee, M., Healy, J., Edwards, N., & Harrison, A. Pressure for change. In Hospitals in a
changing Europe. Buckingham, Open University Press, 2002.
3.
Rachel, B., Wright, S., Dowdeswell, B., & McKee, M. Even in tough times: investing in
hospitals of the future. Euro Observer, 2010, 12(1): 1-12.
4.
Edwards, N., & Harrison, A. The hospital of the future: Planning hospitals with limited
evidence: a research and policy program. British Medical Journal, 1999, 319: 1361-1363.
5.
McKee, M., Edwards, N., & Wyatt, S. Transforming today's hospitals to meet tomorrow's
needs. Administracao Hospitalar, 2004, 4: 21-27.
6.
Beaglehole, R., et al. Improving the prevention and management of chronic disease in lowincome
and middle-income countries: a priority for primary care. Lancet, 2008, 372(9642):
940-949.
7.
Pan American Health Organization. Renewing primary health care in the Americas.
Washington, DC, PAHO, 2007.
8.
Cole, J. Strategic planning of health facilities in Northern Ireland. Euro Observer, 2010,
12(1):1-12.
9.
Institute for Public Policy Research. Hospital reconfiguration. London, IPPR, 2006.
10.
Edwards, N., Wyatt, S., & McKee, M. Configuring the hospital in the 21st century (Rep. No.
5). Copenhagen: The European Observatory on Health Systems and Policies, 2004.
11.
Shortel, S. M., Gillies, R. R., & Anderson, D. A. The new world of managed care: creating
organized delivery systems. Health Affairs, 1994, 13(5):46-64.
12.
Dixon, J., Holland, P., & Mays, N. Developing primary care: gate keeping, commissioning, and
managed care. British Medical Journal, 1998, 317: 125-128.
13.
Hensher, M., Edwards, N., & Stokes, R. International trends in the provision and utilization of
hospital care. British Medical Journal, 1999, 319: 845-848.
14.
Ettelt, S., Nolte, E., Thomson, S., & Mays, N. Capacity planning in health care: reviewing the
international experience. Euro Observer, 2007, 9(1).
15.
The Joint Commission, & Aramark Healthcare. Health care at the crossroads: guiding
principles for the development of the hospital of the future. The Joint Commission, 2008.
Denis Porignon is a medical doctor working as a health policy
expert with the Health System Policy, Governance and Service
Delivery Department (HDS) in WHO Headquarters in Geneva. He
used to work as a clinician and a public health at various levels of
health systems mainly in Africa and Europe. He teaches health
planning and health services organization at the School of Public
Health of the Université Libre de Bruxelles and the Faculty of
Medicine of the Université de Liegè, both in Belgium.
World Hospitals and Health Services Vol. 47 No. 3 9

The evolving role of hospitals in health systems: Dubai
The role of the hospital in the changing
landscape of UAE health care: a focus
on Dubai
AMER AHMAD SHARIF
ADVISOR, HEALTH SYSTEMS DEVELOPMENT, DUBAI HEALTH
AUTHORITY
IAIN BLAIR
ASSOCIATE PROFESSOR, DEPARTMENT OF COMMUNITY
MEDICINE, FACULTY OF MEDICINE AND HEALTH SCIENCES,
UNITED ARAB EMIRATES UNIVERSITY
ABSTRACT: In the UAE, health services have developed greatly in the past 40 years and there have been enormous
improvements in population health. The hospital sector is growing strongly with private sector investment. However the
current and future health needs of the population are complex and may not be properly served by the continued
expansion of hospital capacity. In this paper, using the Emirate of Dubai as a case study, we examine the changes that
have taken place in health services and attempt to predict their optimum configuration and capacity in the future taking
into account population structure and growth and levels of morbidity and service use.
Health has improved dramatically in the UAE in the past 50
years. The under-5 mortality rate has fallen dramatically
from 223 (per 1000 live births) in 1960, to 84 in 1970, 30 in
1980, 17 in 1990, 11 in 2000 and 7 in 2009 1 . For under-5
mortality, UAE is currently ranked 39th amongst the world’s 196
countries 2 . This decline in death amongst children has resulted in
life expectancy increasing over the same period from 53 in 1960
to 78 in 2009.
These improvements in health have been possible because of
the wise investment of oil revenues by the leadership to improve
the social conditions of the population 3 . Investment in health care
provision has also been important, in particular preventative
services and immunization and services for children and women.
Population size, population growth, nationality and age and
gender distribution are all important factors when examining health
needs and health services configuration and capacity.
The last census in UAE was carried out in 2005 when the
population was 4.1 million. At that time, of the seven Emirates that
make up the UAE federation Abu Dhabi, Dubai and Sharjah were
the most populous and overall, 20% of the population were Emirati
nationals. At the end of 2009 the UAE population was 8.2 million
of which only about (11%) were nationals. Currently (2010) the
population of Dubai is 1,905,476 of which 173,635 (9%) are
nationals 4 whereas the population of Abu Dhabi is 2,321,003 of
which 433,769 (19%) are nationals. The UAE population is
growing at an annual rate of 3.3% which places it sixth in the world
rankings 5 . This growth is due both to high net migration (at
19/1000 per year UAE has the world’s third highest net migration
rate) and high natural growth (births minus deaths).
The three main authorities that make up the UAE health care
system are the Federal Ministry of Health (MOH), Dubai Health
Authority (DHA) and the Health Authority of Abu Dhabi (HAAD).
Abu Dhabi is the capital of UAE and the largest of the seven
Emirates. The Government of Abu Dhabi re-organized its health
system in 2006 and introduced a private health insurance and
private provision model. The health authority adopted a strategic
and regulatory role, and a separate health services company
(SEHA) was established to operate government owned health care
facilities.
The Department of Health and Medical Services (DOHMS) of
Dubai was established in 1970 as a local health authority and
service provider for the population of Dubai emirate. DOHMS
continued to be the main local health authority in Dubai even after
the formation of the MoH. In 2007, Dubai Health Authority (DHA)
was formed to oversee health strategy and regulation when it was
separated from health service provision. Private health insurance is
becoming the preferred funding source although Dubai
Government is still an important provider of services. DHA has a
strategic and regulatory role similar to HAAD, but it still operates
its own hospitals and health centres. A free zone entity, Dubai
Healthcare City, has been developed to encourage medical
tourism. In Dubai and Abu Dhabi, the MoH role is now focused on
developing national health strategy and policy but it still has a role
in service provision in the five remaining emirates. UAE nationals
have access to free public sector health care services in Dubai and
the northern emirates while in Abu Dhabi they are covered by a
government funded health insurance scheme. This allows them to
choose from different private providers. Quality of facilities and
services vary between the different emirates and providers. In the
remainder of this paper we will focus mainly on the changes that
have taken place in the Emirate of Dubai.
While prosperity has brought great benefits, it is now threatening
population health in the UAE on a worrying scale. Changes in
lifestyle have contributed to a rising prevalence of overweight and
World Hospitals and Health Services Vol. 47 No. 3 11

The evolving role of hospitals in health systems: Dubai
obesity. These effects are most marked among the national
population, where, as the population has started to age there has
been an explosion in the prevalence of diabetes and
cardiovascular disease. The health of the expatriate population is
better. Here the healthy worker and healthy migrant effect play a
part and most will return to their country of origin before they can
contribute to the overall burden of morbidity.
Lifestyle changes on a population scale are urgently needed to
reduce obesity, CVD and diabetes and reduce the effect of these
diseases on health services. Unlike most western countries, in
UAE, alcohol, drugs and HIV infection are not important public
health determinants but sedentary lifestyles, obesogenic diets,
smoking, road crashes and mental health are all important. While
these changes are underway, it will be important to maintain the
quality and quantity of health services and ensure they continue to
respond to the needs of the population.
How can an understanding of the population structure in Dubai
and an appreciation of the levels of ill-health help health planners
to accurately specify the capacity and configuration of health
services now and in the future? We need to consider two parts of
the population which have different health needs. The national
population and the expatriate population vary greatly in size,
growth, levels of ill-health, the extent to which they will age and
health service utilization. It should be noted that a third population
segment are visitors who increasingly travel to Dubai for medical
tourism purposes.
The national population is currently youthful but it is ageing and
has high levels of morbidity and health service utilisation. The
larger expatriate population is also youthful but it currently has
below average morbidity and low levels of health service utilization.
What changes can be expected in population size over the next
decade? Natural population growth rate (the difference between
births and deaths) is 29/1000 for nationals and 7.4/1000 for nonnationals.
Applying these rates to the population of Dubai
suggests that by 2020, if natural growth rates are maintained the
population of non-nationals will have increased by 8% to 1.86
million and the population of nationals will have increased by 33%
to 230,000. The total population will have grown by 10% to 2.1
million. If in addition there is net inward migration of 10/1000 per
year then the non-national population will rise by 19% to 2.06
million and the total population will be 2.3 million.
How will these changes translate into the need for health
services and hospital capacity?
In the UAE over the past 40 years health services have expanded
greatly. In 1970 there were seven hospitals with 700 beds but by
2005 there were 62 hospitals with 9500 beds. In general bed
numbers have increased in proportion to the increase in
population. Health care is a major component of the Dubai
Strategic Plan 2007-2015 and a major function of DHA when it
was established was to implement the government strategy for
health by 2012. In any health care system hospitals play an
important role, financially (accounting for half of overall health care
expenditure), organizationally (they dominate the health care
system) and symbolically (they are seen by the public as the main
element of the health care system) 7 . Dubai is no exception. The
first clinic started in Dubai in 1943 and building of the first hospital,
the Al-Maktoom Hospital, started in 1951. Now, Dubai has 3 major
public hospitals accredited by JCIA and a new rural hospital in
Hatta area. To ensure a supply of well-educated health care
professionals, DHA hospitals have developed continuing
education and residency programs. Specialized centres have
been established including a Trauma Center and a Thalassaemia
Center. The Hospital Services Sector (HSS) was created by DHA
as the governing body of all government hospitals and specialty
centres. Private sector hospitals, which are regulated through the
DHA Health Regulation Department, have also developed and
have obtained international accreditation as a means of
demonstrating quality.
In Dubai in 2006 there were seven public (MOH and DOHMS)
hospitals with 2021 beds and 18 private hospitals with 913 beds 8 .
At that time 31% of bed capacity in Dubai was in the private sector
which accounted for 32% of inpatient activity. However 90% of
clinics and health centres, 78% of physicians and 58% of
outpatient attendances were provided by the private sector. By
2010/11 there will be further 1075 beds in 9 new or expanded
private hospitals and 1006 beds in 12 facilities within Dubai Health
Care City (DHCC). This means that at that time, of the 5000
hospital beds available in Dubai (2.6 beds/1000 population), 20%
will be provided by DHCC, 40% by the rest of the private sector
and 40% by the Government (6% MOH, 34% DHA). This is fully in
line with Dubai Government plans to expand private sector
provision, encourage private and social health insurance and
improve access to services.
But will this expansion meet population health needs?
Morbidity is less amongst non-nationals and so their need for
hospital services will not rise at the same rate as amongst
nationals although the introduction of mandatory health insurance
may lead to supply side increases in service use. Nevertheless the
high levels of morbidity amongst nationals and the continued
growth in medical tourism should be well catered for by these
increases in hospital capacity and specialities.
International benchmarks are often used to predict the optimum
number of hospital beds and physicians for a given population.
Obviously these benchmarks are dependent on the levels of
morbidity in the population and this usually dependent on the age
distribution within the population. Also countries and jurisdictions
vary in the nature of the service they offer. Those with welldeveloped
chronic disease management services, nurse led
services and availability of step-down and nursing home
accommodation have reduced the numbers of beds and
physicians that are needed to meet health needs. Nevertheless a
benchmark or norm of two physicians and two hospital beds per
1000 population are widely accepted. Currently the ratios in Dubai
are 2.6 beds and 2.8 physicians per 1000 population. These
figures might suggest over-capacity of hospital beds and
physicians and should prompt a critical examination of the health
needs of the Dubai population, both national and expatriate and
medical tourists to ensure the capacity and configuration of
hospital services are accurately meeting health needs in the most
cost-effective way.
Conclusion
UAE health services have developed greatly in the past 40 years
and this has coincided with enormous improvements in population
12 World Hospitals and Health Services Vol. 47 No. 3

The evolving role of hospitals in health systems: Dubai
health. However the current and future health needs of the
population are complex and may not be properly served by the
continued expansion of hospital capacity. The hospital sector is
growing strongly fuelled by private sector investment with
business cases predicated on population growth, high levels of
morbidity, universal health insurance and medical tourism.
This may not be the best model of care. Rising levels of
morbidity amongst nationals will require the development of
chronic disease management programs that support screening,
prevention and self-care. Community based generalist services will
be more effective than hospital based specialist services. The
expatriate population also has unique health needs. This
population has low morbidity so that ambulatory care,
occupational health and preventative services offer the greatest
benefits. Good electronic health records will be required to avoid
excessive, inappropriate use of services.
It is to be hoped that careful planning by health authorities,
continued investment in health services and the growing influence
of the private sector will allow the health needs of nationals,
expatriates and medical tourists alike to be satisfactorily met by
the development of a comprehensive range of modern, highquality
health services. ❏
References
1.
Gapminder website. http://www.gapminder.org/ [accessed September 2011]
2.
United Nations Children’s Fund. The State Of The World’s Children 2011: Adolescence an Age
of Opportunity. Unicef, New York, 2011. Available at:
http://Www.Unicef.Org/Sowc2011/Pdfs/Sowc-2011-Main-Report_En_02092011.Pdf
[accessed September 2011]
3.
Rosling H. Health Development in the United Arab Emirates from a Global Perspective. United
Arab Emirates: The Emirates Center for Strategic Studies and Research 1999. Emirates
Lecture Series No. 23.
4.
Population of Emirate of Dubai 2010 [webpage on the Internet]. Government of Dubai, 2010
[cited September 2011] Available from:
http://www.dsc.gov.ae/Reports/DSC_SYB_2010_01_01.pdf
5.
The World Factbook 2009 [webpage on the Internet]. Washington, DC: Central Intelligence
Agency, 2009 [cited July 2011] Available from: https://www.cia.gov/library/publications/theworld-factbook/index.html
6.
Health Authority Abu Dhabi, 2010. Health Statistics 2010. Available from
http://www.haad.ae/HAAD/LinkClick.aspx?fileticket=c-lGoRRszqc%3d&tabid=349 [accessed
September 2011].
7.
McKee M, Healy J. The role of the hospital in a changing environment. Bulletin of the World
Health Organization 2000; 78 (6): 803-810.
8.
Dubai Health Authority Website. www.dha.gov.ae [accessed September 2011]
Dr Amer Ahmad Sharif is currently an Advisor on Health System
Development at Dubai Health Authority (DHA). Prior to his current
appointment he was the Director of the Continuing Medical
Education and subsequently became the Director of Human
Resources at DHA. Simultaneous with his appointment in the Dubai
Health Authority, he is doing his PhD in Public Health at the Faculty
of Medicine and Health Sciences (FMHS), UAE University (UAEU),
and his research is mainly focusing on critically evaluating the UAE
health care system. Dr Sharif obtained his Medical degree at
FMHS, UAE University in 2003 and earned his Master of Science
(MSc) in Healthcare Managementat Royal College of Surgeons of
Ireland (RCSI) in 2007.Dr Sharif has been involved in undergraduate
and postgraduate teachings at the FMHS, and an invited lecturer
for the MSc in Healthcare Management program at RCSI-Dubai. Dr
Sharif was awarded the Best Employee award by the Dubai Health
Authority and received the prestigious Sheikh Rashid Award for
Excellence for Distinguished Students, for being the gold medalist
at the FMHS, UAE University.
Dr Iain Blair is Associate Professor in the Department of Community
Medicine, Faculty of Medicine & Health Sciences, United Arab
Emirates University (UAEU). He is Director of the UAEU Master of
Public Health programme, interim Director of the UAEU Global
Health Institute and an external examiner for the University of
Malaya in Kuala Lumpur. Having trained as a general practitioner,
he worked in Canada and the Middle East before commencing
training in public health in the UK in 1986. In 2003 with the
establishment of the Health Protection Agency he became Director
of the Black Country Health Protection Unit (HPU). In 2008 he
moved to the UAE. He has published articles on surveillance and
health protection and is a co-author of Communicable Disease
Control Practice a major international textbook on health
protection. His current research interests are the social and
environmental determinants of modern lifestyle diseases in the UAE
and the effect of chronic illness on the Emirati family.
World Hospitals and Health Services Vol. 47 No. 3 13

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The evolving role of hospitals in health systems: USA
Hospitals of the future
RICHARD J UMBDENSTOCK
PRESIDENT AND CHIEF EXECUTIVE OFFICER, AMERICAN
HOSPITAL ASSOCIATION (AHA)
MAULIK S JOSHI,
PRESIDENT OF THE HEALTH RESEARCH & EDUCATIONAL TRUST
(HRET) AND SENIOR VICE PRESIDENT OF RESEARCH, AMERICAN
HOSPITAL ASSOCIATION (AHA)
JILL SEIDMAN
PROGRAM MANAGER FOR HOSPITALS IN PURSUIT OF EXCELLENCE,
AMERICAN HOSPITAL ASSOCIATION (AHA)
ABSTRACT: Hospitals and health systems face unprecedented demand to change in both the near- and longer-term
future, ranging from demographic changes to increasing reliance on value-based payment, and to the uncertainty
surrounding governmental reform. The American Hospital Association Board Committee on Performance
Improvement embarked on an initiative to identify the top ten strategies all hospitals must adopt in order to be
successful care systems of the future. As a result of the committee’s survey research, four top strategies were
identified: 1) Aligning hospitals, physicians, and other providers across the continuum of care; 2) Using
evidenced-based practices to improve quality and patient safety; 3) Improving efficiency through productivity and
financial management; and 4) Developing integrated information systems. This article summarizes ten strategies
and the measures to assess the accomplishment of these strategies.
Hospitals and health systems face unprecedented demand
to change, now and in the future. From radically changing
demographics and payment systems to the uncertainty
surrounding governmental reform legislation, these pressures
combine to create substantial concerns among health care
leaders.
In the current financial environment, hospitals must focus their
efforts on performance initiatives that will pay dividends now and
also position them for success in the long term. This reality
inspired the American Hospital Association’s (AHA) Board
Committee on Performance Improvement to center their initial
project on the “hospital of the future.” Economic, demographic,
and regulatory changes are occurring throughout the health care
industry and compete for organizations’ attention. This article aims
to cut through the competing messages to synthesize the bestpractice
strategies hospitals can adopt today to reach tomorrow’s
desired care delivery models
Approach
The strategies put forward in this article are the result of telephone
and in-person interviews conducted with senior leaders from
health systems, hospitals, and stakeholder organizations. Those
interviewed represent a comprehensive cross-section of
geographically diverse providers. These providers have various
physician affiliation and employment models.
The AHA Committee on Performance Improvement synthesized
the results of the interviews and identified the most important
actionable strategies for organization-wide implementation. To
prioritize the results, the strategies were voted on by members
from various AHA regional board and constituency groups. The
hospital leadership members were asked to vote on the most
urgent of the strategies, thereby developing the list appearing on
the follow pages. This list of strategies articulates a broad vision of
the future of the hospital.
First Curve to Second Curve
Economic futurist Ian Morrison believes that changing payment
incentives will cause hospitals to modify their business and service
delivery models. He calls this a first-curve to second-curve shift.
As displayed in Figure I, the first curve displays where providers
have come from. It is an economic paradigm driven by the volume
of clinical services, fee-for-service reimbursement, and
competition between providers. The second curve is where
hospitals will go because of changing payment incentives and is
concerned with value. It is a paradigm centred on the cost and the
quality of care. It stresses system affiliations rather than
competition. This paradigm shift is necessary to produce desired
health outcomes.
Morrison finds that the current system has not yet left the first
curve and has not arrived at the second. Instead, he refers to the
current market as “the gap.” Managing during this period requires
an evolving equilibrium on the role of all involved. Providers that
implement second-curve economics before the market is ready
may see significant revenue reduction. Conversely, those that
remain in the first curve and do not organize themselves will not
gain the capabilities to succeed when market transition is
complete. Life in the gap is challenging on its own. As the number
of pilot programs that demonstrate life in the second curve
World Hospitals and Health Services Vol. 47 No. 3 15

The evolving role of hospitals in health systems: USA
Strategy #1: Aligning hospitals, physicians, and other providers across the continuum of care
First-Curve to Second-Curve Metrics for Physician Alignment
Number of physicians on staff
Financial profit and loss from employed physicians
Hospitalist utilization
Number of non-acute services contracts
Number of aligned and engaged physicians
Percentage of provider contracts with quality and efficiency incentives
Availability of non-acute services
Distribution of shared savings to aligned clinicians
Number of lives covered though an accountable care type organization
Number of providers in leadership
Strategy #2: Using evidence-based practices to improve quality and patient safety
First-Curve to Second-Curve Metrics for Quality and Patient Safety
Medicare core measure standards
Patient experience/satisfaction
Facility-specific quality and safety measures
30-day readmission rates
Effective management of care transitions
Management of utilization variation
Preventable admissions, readmissions, ED visits, and mortality
Reliable patient care processes
Active patient engagement
Strategy #3: Improving efficiency through productivity and financial management
First-Curve to Second-Curve Metrics for Physician Alignment
Staffing ratios
Cost per inpatient stay
Operating margin
Length of stay
Expense per episode of care
Shared savings from performance-based contracts
Targeted cost reduction goals
Management to Medicare margin
Strategy #4: Developing integrated information systems
First-Curve and Second-Curve Metrics for Integrated Information Systems
Number of HIT systems implemented
Data extracted
Information exchange across providers
Integrated data warehouse
Lag time between analysis and result availability
Understanding of population disease patterns
Use of health information across care continuum and community
Real-time information exchange
Active use of patient health records
continues to grow, each institution will have to determine the
appropriate time to make its leap to the new paradigm.
Findings
By considering in tandem the shift from the first curve to the
second curve as well as the findings from the interviews, the
following 10 strategies were identified as critical to implement for
all hospitals.
Must-Do Strategies*
✚ Aligning hospitals, physicians, and other providers across
the continuum of care.
✚ Using evidenced-based practices to improve quality and
patient safety.
✚ Improving efficiency through productivity and financial
management.
✚ Developing integrated information systems.
✚ Joining and growing integrated provider networks and care
systems.
✚ Educating and engaging employees and physicians to create
leaders.
✚ Strengthening finances to facilitate reinvestment and
innovation.
✚ Partnering with payers.
✚ Advancing through scenario-based strategic, financial, and
operational planning.
✚ Seeking population health improvement through pursuit of the
Institute for Healthcare Improvement’s “Triple Aim” of
improving the health of the population, enhancing the patient
experience of care (including quality, access, and reliability),
and reducing, or at least controlling, the per capita cost
of care.
*Strategies in bold represent top-priority strategies and will be accompanied by
metrics on the following pages.
These priorities represent actions that organizations should
consider instituting now to manage life in “the gap” and to help
propel to them to the second curve. They will help providers be
more successful until payment incentives like value-based
payment arrive and push the entire health care system into the
second curve.
16 World Hospitals and Health Services Vol. 47 No. 3

The evolving role of hospitals in health systems: USA
FIGURE 1: First curve to second curve
Volume to Value
Volume-based First Curve
Fee-for-service reimbursement
High quality not rewarded
No shared financial risk
Acute inpatient hospital focus
IT investment incentives not
seen by hospital
Stand-alone care systems
can thrive
Regulatory actions impede
hospital-physician collaboration
THE GAP
Time
Organizational culture is an essential foundation to support the
execution of the must-do strategies. A culture of performance
improvement, accountability, and high-performance focus is
critical to the organization’s ability to implement these strategies
successfully.
The strategies detailed below are non-exclusive. Organizations
cannot expect to pursue just one strategy and remain successful
in the second curve. However, the prioritization will not be the
same for every hospital and will depend on the organization’s
capabilities, potential for external collaboration, and market
demographics. The metrics provide an example of how
organizational thinking needs to change around each topic in
order to move from the first to the second curve. Metrics are
provided for only the top four priorities.
Strategy #1: Aligning hospitals, physicians, and other
providers across the continuum of care
Market and regulatory forces are putting pressure on hospitals and
physicians to pursue employment strategies and other ways to
align. Hospitals are partnering with physicians to improve care
coordination and thus reduce unnecessary admissions.
Physicians seek hospitals as partners in the face of higher
administrative costs and the threats of decreased reimbursement.
Seventy-four percent (74%) of hospital leaders participating in a
2010 survey revealed that they planned to increase their number
of employed physicians over the next year. However, interviewees
overwhelmingly said that simply employing physicians only
secures alignment of financial incentives. To succeed in the
second curve, hospitals must collaborate with physicians on
Partnerships with shared risk
Increased patient severity
IT utilization essential for
population health management
Scale increases in importance
Realigned incentives,
encouraged coordination
Source: Hospitals and Care Systems of the Future Report, AHA Committee on Performance
Improvement, September 2011, www.aha.org. Adapted from Ian Morrison, The Second Curve,
Ballantine Books, 1996.
Value-based Second Curve
Payment rewards population value:
quality and efficiency
Quality impacts reimbursement
quality and strategic objectives in
addition to those surrounding
economic considerations. Alignment
arrangements have the ability to create
a system in which all parties are
accountable for achieving high
performance, reaching patient-centred
goals, and eliminating unnecessary
costs. A symbiotic system such as this
is beneficial to all in a value-based
payment world.
Strategy #2: Using evidencebased
practices to improve
quality and patient safety
Although considerable gains have
been made within defined areas of
quality and patient safety, moving to
the second curve requires widespread
expansion of these programs. In a
year, Medicare (government coverage
for the elderly) spends $17 billion, or
20%, of all Medicare payments
on unplanned readmissions. In
2013, payment for unnecessary
readmissions is scheduled to be
eliminated. This demands quality at
the inpatient site of care. In addition to
the readmissions policy, potential new
value-based models tie quality to financial reimbursement. Several
methodologies have been deployed in the mission to improve
quality, ranging from use of evidence-based medicine and patientfocused
care delivery to bundles of care and multidisciplinary team
training. Moving to the second curve requires measurement,
analysis, and reducing clinical variation to improve quality.
Strategy #3: Improving efficiency through productivity
and financial management
The demand for increased efficiency is felt on all sides of the
acute-care organization. Providers fear that by 2025, the projected
combination of a 29% increase in primary care workload and only
2%–7% growth in the number of primary care physicians will
overstress their systems. In addition, the focus on quality-based
reimbursement combined with tightening margins requires
hospital leadership to eliminate duplicative efforts and standardize
processes through a combination of operational improvements
and redesigned care-delivery models. While some organizations
have improved efficiency and cost management through a focus
solely on quality and access, others are considering financial
margins throughout process improvement projects.
Strategy #4: Developing integrated information systems
The policy arena has positioned health information technology
(HIT) as a key to health system cost reduction, predicting it will
decrease administrative overhead, duplicative tests, paperwork,
and medication errors. The 2009 Health Information Technology
for Economic and Clinical Health Act within the American
Recovery and Reinvestment Act provided a financial incentive for
World Hospitals and Health Services Vol. 47 No. 3 17

The evolving role of hospitals in health systems: USA
physicians and hospitals to adopt electronic health records.
However, interviews revealed that organizations that installed HIT
systems have found literacy, cultural, and work flow barriers are
even more critical than cost to a successful organization-wide
implementation. Despite the difficulties, well-established and
utilized systems are critical to future success in the second curve,
connecting providers and providing critical real-time information to
actively plan, measure, and improve efficiency and quality from the
bedside to the C-suite. It is not enough to possess information
systems or extract “important” data. The ability of an organization
to leverage technology to perform sophisticated data mining and
analysis in real time is critical for long-term organizational
sustainability and care improvement.
Strategy #5: Joining and growing integrated provider networks
and care systems
The interviews revealed that a large majority of organizations have
already extended their care reach or are in the process of doing
so. These expansions come in a variety of forms: mergers; comanagement
agreements; acquisitions; and strategic alliances of
hospitals, ambulatory facilities, physician groups, and other
providers. In a challenging environment, organizations have
recognized that well-chosen partnerships with joint accountability
for both outcomes and cost provide the opportunity to coordinate
care, improve quality, increase efficiency, leverage expensive
technology, increase profitability, and achieve service excellence.
The second curve commands a dedication to the overall patient
population, and these affiliations expand an organization’s ability to
manage patient health across the continuum. Beyond traditional
acute-care partnerships, health systems will begin to collaborate
with community, public health, government, and education
agencies. This will require the development of new competencies
for many management teams. While interviews revealed that the
same model will not be successful for every organization, thriving
relationships have traditionally displayed proven benefits to all
involved parties.
Strategy #6: Educating and engaging employees and physicians
to create leaders
Long-term success of health care organizations is based on the
culture, desire, and dedication of their employees. To thrive in a
second-curve market, every clinical and administrative employee
must be involved in initiatives to control expenses, improve
efficiency, and increase quality. This can be accomplished with a
variety of educational and involvement strategies. As physicians
continue to become more aligned with the interests of acute-care
facilities, it is essential to provide leadership training to clinicians
who can guide the integration process.
Strategy #7: Strengthening finances to facilitate reinvestment
and innovation
Hospitals must prepare for tightening margins. The future of
decreased reimbursement and a severe case-mix requires
organizations to cut costs and improve operating margins without
sacrificing quality. Simultaneously, new technologies are available
that can significantly improve patient outcomes but require a huge
financial investment. Interviewees commented that without
improving current operating margins, they would not have the
financial resources to perform any of the other must-do strategies.
To achieve the financial status desired for future innovation,
organizations will have to revise their current service offerings,
policies regarding capital, and management structure to reduce
fixed costs throughout their budget.
Strategy #8: Partnering with payers
In the current fee-for-service reimbursement system, payers have
the most potential to realize savings. This will continue unless new
provider arrangements are made. As both CMS and commercial
payers increasingly reward clinical integration and high-quality
care, providers must assume greater accountability. For these
reasons, the majority of interviewed organizations have considered
or have already entered into contractual arrangements with payers
to align risk and potential rewards. Accountable care organizations
will probably not be the appropriate arrangement for all
organizations. However, it is essential for institutions to involve
their clinical staff throughout the process of considering new
arrangements with payers, both to receive buy-in, and to explore
together ways to make clinical quality improvements that might be
able to reduce costs overall.
Strategy #9: Advancing through scenario-based strategic,
financial, and operational planning
In a turbulent and unpredictable market facing economic and
regulatory changes, organizations must move beyond traditional
future-focused strategic planning. They must use methods that
prepare their organizations for a large number of potentially new
situations and incorporate financial and operational considerations
into their plans. This advanced method of strategic planning
requires a strong basis in financial management, risk assumption,
and established core-planning capabilities. Institutions should
ensure they create a flexible infrastructure that will prepare them
for any scenario, health exchanges and Medicaid cuts to natural
emergencies and the loss of large, local employers. Successful
strategic planning is market- and organization-specific, and this
process allows for the entire team to determine their future
direction and success within the second-curve market.
Strategy #10: Seeking population health improvement through
pursuit of the Institute for Healthcare Improvement’s “Triple
Aim” of improving the health of the population, enhancing the
patient experience of care (including quality, access, and
reliability), and reducing, or at least controlling, the per capita
cost of care
In a cooperative environment, hospitals historically were able to
leave population health considerations to public health officials
and organizations throughout their market area. However, the
aging population and value-based payment have encouraged
hospitals to take a more prominent role in disease prevention,
health promotion, and other public health initiatives. The “Triple
Aim” is an initiative launched by the Institute for Healthcare
Improvement in 2007 to encourage hospitals to focus
simultaneously on improving population health, increasing
quality, and reducing health care cost per capita. The pursuit of
these three goals permits organizations to identify and fix a wide
range of problems, but most importantly, it allows them to
redirect resources to activities that will have the greatest impact
18 World Hospitals and Health Services Vol. 47 No. 3

The evolving role of hospitals in health systems: USA
on overall health. For the organizations interviewed, these
activities included community-wide education and wellness
projects, disease screening initiatives, and chronic disease
management programmes 6 .
Conclusion: Implications for the future of hospitals
This article should help motivate hospital senior leadership teams
to consider the strategies they must deploy throughout their
individual organizations to adapt and succeed in the future.
Consensus exists that change will occur; what varies is each
organization’s path to embrace the hospital and care system of the
future. Despite the current uncertainty in health care, there is much
that hospitals can do now that will better position them for
success in the future. By implementing a set of top ten strategies,
and in particular, by aligning all providers along the continuum of
care, improving quality, patient safety and efficiency and
integrating information systems, hospitals will be prepared to
succeed in the future. ❏
References
1.
Ian Morrison, The Second Curve. Ballantine Books, 1996.
2.
Cantlupe, J. Physician Alignment in an Era of Change. HealthLeaders Media Intelligence.
www.healthleadersmedia.com/intelligence, Sep. 2010. Accessed July 2011.
3,
Jencks, SF et al. Rehospitalizations among patients in the Medicare Fee-for-Service
Program,” N Eng J Med 2009. 360(14): 1418-1428.
4,
Bodenheimer, T et al. Primary Care: Current problems and proposed solutions. Health Affairs
2010. 29:799-805.
5,
Bakhtiari, E. Don’t Skimp on Physician Leadership Development. HealthLeadersMedia. March
12, 2009. Accessed August 2, 2011.
6,
McCarthy, D et al. The triple aim journey: improving population health and patients’
experience of care, while reducing costs. The Commonwealth Fund. Vol. 48. July 2010.
Richard J Umbdenstock is president and chief executive officer of
the American Hospital Association, which represents more than
5,000 member hospitals, health systems and other health care
organizations, and 40,000 individual members. He serves on the
National Quality Forum Board of Directors and the National
Priorities Partnership, and chairs the Hospital Quality Alliance.
Maulik S Joshi, Dr PH is President of the Health Research &
Educational Trust (HRET) and Senior Vice President of Research at
the American Hospital Association (AHA). Dr Joshi has a doctorate
in public health and a master's in health services administration
from the University of Michigan and a bachelor of science in
mathematics from Lafayette College. Dr Joshi is Editor-in-Chief for
the Journal for Healthcare Quality. He also co-edited The
Healthcare Quality Book: Vision, Strategy and Tools and authored
Healthcare Transformation: A Guide for the Hospital Board
Member.
Jill Seidman iis a program manager for Hospitals in Pursuit of
Excellence, AHA’s strategic platform to assist hospitals in
accelerating performance to improve quality of care. She is
responsible for the content behind actionable guides and other
literature that supports AHA members’ strategic initiatives.
World Hospitals and Health Services Vol. 47 No. 3 19

The evolving role of hospitals in health systems: USA
The underlying theories of health
care reform in the United States –
Strategy implications
for hospitals
DANIEL B MCLAUGHLIN
DIRECTOR OF THE CENTER FOR HEALTH AND MEDICAL AFFAIRS,
UNIVERSITY OF ST THOMAS IN MINNEAPOLIS, MINNESOTA,
USA
JACK MILITELLO
PROFESSOR OF MANAGEMENT AND DIRECTOR IF THE HEALTH
CARE AND EXECUTIVE MBA PROGRAMS, UNIVERSITY OF ST
THOMAS IN MINNEAPOLIS, MINNESOTA, USA
ABSTRACT: The United State Health Reform (Affordable Care Act) presents health care providers with the goals that should
be achieved in the reformed health care environment and the rationale for those goals. Developing strategies to implement
the act’s policies by any health care organization must take into account the underlying theories of the act:
• Managed change though payment design and funds flow
• Market place competition
To execute strategy effective internal organizational management is a must and can be facilitated through a strong
alignment between mission and operating factors. The mission must relate to the organization’s markets. Markets are best
addressed through a local perspective where the ACA goals can be applied within a specific community or culture. The
systems approach brings as many participants in the system to define their mutual success as it relates to reform.
The Affordable Care Act (ACA) provides the United Sates with
the national goals of healthy individuals, healthy
communities, and a true system of heath service delivery. It
is the result of years of policy research, demonstration projects,
pilot studies, and a review of the best practices of health care
organizations throughout the world. The law contains ideas and
theories that have been advanced by both Democratic and
Republican legislators over the past twenty years. The overall
outcomes are connected to universal access, cost controls, and
quality improvement. However the ACA does not direct hospitals
or other health care related organizations on how to implement its
legislation. Implementation is the strategic challenge of all health
care providers.
This article addresses a set of strategic responses hospitals
might take in implementing ACA legislation. The authors have
organized the ACA into two theoretical categories: funds flow and
markets. Suggested strategic responses are organized in light of
these two theories and in the context of a systems approach to
strategic outcomes.
ACA organizing theories
Funding design can influence behaviour and the ACA has many
funding policies which are based on successful demonstration
projects.
A highly visible example is the Physician Group Practice
demonstration which defined the Accountable Care Organization
(ACO) in the ACA. ACOs provide comprehensive care for a
defined population for a preset price. One of the most successful
demonstration sites was the Marshfield Clinic.In three years the
clinic met greater than 98% of its 32 quality measures and
received a performance payment of 13.8 million, generating a
$23.49 million Medicare savings in the third year 1 .
Another demonstration was focused on bundled payments for
inpatient care. In this demonstration the Baptist Health System
was paid a flat bundled rate for 9 orthopedic and 28 cardiac
procedures. This fee included hospital care, physicians and
outpatient follow up and rehabilitation. Physician payments were
increased by 25% if certain cost reduction targets and quality
goals are met. The project and immediately generated gain
sharing payments from Medicare that ranged from $65.00 to
$6000.00 per admission 2 .
These demonstrations supported the ACA theory that, with the
proper incentives in place, cost can be contained as good service
is provided. In many of its policies the ACA reform addresses the
incentive system with scheduled cost containments and
controlled pricing. Hospitals must now react to these Medicare
initiatives.
A second underlying theory of the ACA is that a fully functioning
and competitive market for health care services will achieve the
goals of reform. The ACA bases this position on a demonstration
20 World Hospitals and Health Services Vol. 47 No. 3

The evolving role of hospitals in health systems: USA
Figure 1: Total Health System Model
Financial resources
and goals
Facilities
Health Care
Workers
Information
Technology
Information
Market/Clinical
Medical Technology
(Pharm., devices)
Consumer Behaviour
Tools – Diagnosis
and Treatment
Professional
Patient
Past Experience-
Personal, networks
Financing Sources
and Structure
Knowledge
Illness Burden
Government
Continuing Education
Genetics of
the Individual
For profit health plans
Primary Education
Individuals
Research
Environment:
Air, food, water,
economic and cultural
in Massachusetts which has successfully implemented large
group purchasing for individuals. It succeeded in insuring 98.1% of
the Massachusetts population 3 . However it has not had a
significant effect on restraining cost growth.
A second demonstration of controlled market competition is
the Medicare drug benefit Part D. In this case Medicare
beneficiaries chose from over 30 drug benefit plans each year.
The cost of the average drug plan is now 41% below what was
originally forecast 4 .
The ACA sets a direction for health care reform through the
theories of funds flow and markets. Now the managers of the
health care organizations need to bring together these two
theories into an operational perspective. A systems approach
can be the way to strategically do so. In the opinion of the
authors, a systems approach, which is at the heart of the ACA,
is drawn from the Clinton Health Care Reform plan of 1993. At
that time over 40 topical l working groups were formed
containing subject matter experts from all aspects of the broader
health care system. This process set the tone for defining and
resolving inter-health sector conflicts and could serve a vital role
in current health care reform implementation.
The strategic response
Any strategic response to funds flow and markets has to be taken
in relation to the each other and in the context of the broader
health care system. A discrete response to the administrative
pricing directives in the ACA is quite simple: cut costs and retrench
to meet pricing constraints or seek new venues to gain revenue.
The former is currently undertaken through a number of initiatives
accepted within the hospital industry. They include analytically
based cost containment; operational improvement protocols; and
employee motivational development. These initiatives are
necessary but not sufficient to strategically succeed in the ACA’s
reformed environment. The latter demands the application of each
of these tools with the addition of an engagement with competing
business models; potential partnerships; community and
governmental relationships; generational culture differences; and
the power of the consumer. In short, it demands a systems
perspective on strategy.
There are four perspectives 5 health care providers can bring to
a systems approach to reform.
One: A systems approach begins when first you see the
world through the eyes of another. The health care delivery
World Hospitals and Health Services Vol. 47 No. 3 21

The evolving role of hospitals in health systems: USA
system is a conglomeration of a myriad of business models,
ranging from nonprofit services through return-on-investment
models for publically traded companies. The hospital’s health care
delivery system might begin from the patient provider interaction
but then takes in all the suppliers of goods and services which
support this core interaction. Figure 1 provides one example of a
system’s model centered on the patient and provider. Hospital
administrators must understand that various stakeholders bring
many possible approaches to the transaction, with their own
needs and constraints.
Two: A systems approach goes on to discover that every
business plan is terribly restricted. The points of view of the
systems stakeholders can be only known imperfectly and
relationships based on objective information are impossible to
create. Therefore it becomes the role of the administrators of these
systems to challenge each other’s assumptions. This means
engaging in a dialog that challenges each other’s thinking behind
competing business models with the aim of finding a space where
agreements can be reached.
Three: There are no experts in the systems approach. These
who embark on a strategy to address the health care system as a
whole may become frustrated in the face of sectional interests.
The systems planner must address those factions with a spirit of
dialog and with an understanding that the complexity of the health
care system brings with its various business models and a variety
of moral judgments and ethical considerations. In such a system
there can be no experts, merely participants in the dialogue.
Four: The systems approach is not a bad idea. The attempt
to take on the whole system remains a worthwhile ideal, even if it
cannot be fully realized in practice. The complexity of health care
has frustrated many good thinkers at the personal, organizational,
and governmental levels. So, administrators should pick the place
where they can enter the system dialog and be most effective.
Implementation of a system strategy
With the assumptions that health care reform is built on the two
theories of funds flow and markets and that a systems approach
to strategy is an appropriate one, the following are strategic
initiatives that hospitals can take.
Align the internal system
A reference projection is the recommended way to begin a
strategic process. The SWOT Analysis is probably the most
familiar reference projection tool. However a systemic reference
projection can also be provided though an alignment analysis. The
health care organization should first determine its strategic
purpose and, then, conduct an analysis to see how organizational
factors such as know-how, culture, management practices, etc.
align with purpose. Research has shown that organizations that
align management factors with purpose realize superior financial
performance over those who do not 6 .
It ought to be noted that an organization’s purpose should
express its vision, either implicitly in its goals or explicitly in a clear
statement of mission. Mission statements are often high-minded
but lacking in connection to actual operational management of the
organization’s assets. A clear mission should state long-term goals
and determine how to measure progress toward reaching them
and should provide the organization with a business model that
provides a distinctive competitive advantage. An alignment
analysis would situate any health care provider with the insight as
to how to approach its markets.
It is the ultimate alignment of the provider’s business design,
market approach, and human assets that allow for a robust
strategy. It is the clear statement of purpose that brings these
factors together into a viable management system. The ACA does
not dictate management behaviors. So, the management
imperative is that health care provider’s internal alignment must be
strong in order to perform in a market.
The market approach
Much of the ACA is based on the theory that strong market
competition will drive improved overall provider performance.
Market viability in health care has been challenged by economists
because of the fact that patients are not always the direct
purchasers of health care services 7 .) This may be the case.
However, contemporary technologies have created a
knowledgeable consumer class that has more participation in all
its purchases, including health care. This is true in both personal
health and in health care itself. Awareness of healthy choices for
consumers is becoming part of our everyday discourse. People
are exposed, at the least, to health choices and the consequence
of choice. Likewise, health care providers are becoming more
consumer-sensitive. Firms such as Target and Walmart, among
others, are bringing health care to retail settings and further
alerting people to the market choices in the field. These and other
activities, such as health savings accounts, are creating markets
for health care and are also enlightening people to the fact that
they represent a market
From a systems perspective, health care organizations are
embedded in a social context of relationships. For many health
care providers these relationships are local and are open to
localized market information. .A strategic market response to the
ACA would be to look at local and regional organizational
positioning. While national policy makers think only in terms of a
national mandate for quality and costs, a valid strategic response
to the ACA would be in community partnerships, health products
and services that represent regional preferences, and services that
can attract local constituents to programming that is social in
nature. Effective health care leaders will see how supermarkets,
financial services institutions, and colleges market locally to their
constituents and see what can be learned from them.
Spread the dialogue across the system
The systems theory underlying the ACA should create willingness
among health care providers to engage in strategic discussions
with suppliers to their organizations. Trade associations bring
similar organizations together to discuss shared concerns. There
are few venues where a wide array of health care systems
stakeholders can participate in a similar dialogue.
All parties within the health care system need to negotiate with
each other with both their own interests in mind and the overall
concern for healthy people, healthy communities, and a healthy
delivery system in mind. This relationship driven approach to the
system can assist administrators to learn their way to desirable
and feasible change. Any competitive stance between provider
and supplier would have to be eased in the dialogue process but
22 World Hospitals and Health Services Vol. 47 No. 3

The evolving role of hospitals in health systems: USA
can open up novel and elegant proposals for systems improvement.
Conclusion
The ACA presents health care providers with the goals that should
be achieved in the reformed health care environment and the
rationale for those goals. The implementation of any health care
reform lies with the stakeholders in the system itself. Effective
internal organization management is a must and can be facilitated
through a strong alignment between mission and operating
factors. The mission must relate to the organization’s markets.
Markets are best addressed through a local perspective where the
ACA goals can be applied within a specific community or culture.
The systems approach brings as many participants into the
system to define their mutual success as it relates to reform. ❏
References
1.
Praxel, T. A. 2009. “Quality Improvement in the Marshfield Clinic.”Presentation at the Institute
for Clinical Systems Improvement Annual Meeting, Oct. 26.
2.
My San Antonio. 2009. “Providers Nationwide Watch Medicare Experiment Here.” [Online
article; published 10/12/09.]www.mysanantonio.com/default/article/Providers-nationwidewatch-Medicare-experiment-844486.php#page-1
3.
Blue Cross Blue Shield Foundation (2011) Health Reform in Massachusetts – Assessing the
Results
4.
David Brooks, (6/11/2011) Where Wisdom Lies, New York Times
5.
C. West Churchman(1968). The Systems Approach. Dell Publishing, New York
6.
John F. Militello and Michael A. Sheppeck (2007).Determining Organizational Alignment: A
Research Model. Journal of Business and Behavior Sciences, Vol.15, Iss.1.
7.
Kenneth J. Arrow (1963). Uncertainty and the Welfare Economics of Medical Care. The
American Economic Review, Vol. LIII, No.5.andJoseph White (2007). Markets and Medical
Care: the United States, 1993 – 2005. The Milbank Quarterly, Vol.85, No.3.
Dan McLaughlin is the Director of the Center for Health and
Medical Affairs at the University of St Thomas in Minneapolis
Minnesota. His research is focused on operations management
and leadership. He is the author of Healthcare Operations
Management and Responding to Healthcare Reform: A Strategy
Guide for Healthcare Leaders.
Jack Militello is a Professor of Management and Director of the
Health Care and Executive MBA Programs at the University of St
Thomas in Minneapolis, Minnesota. His research, consulting, and
teaching help leaders development and implementation sound
strategies. He holds a PhD from the Wharton School of the
University of Pennsylvania in Social Systems Sciences
World Hospitals and Health Services Vol. 47 No. 3 23

The evolving role of hospitals in health systems: Brazil
Effects of payment mechanisms on
hospital behaviours in Brazil:
evidence from a multi-payer and
multi-payment system
BERNARD F COUTTOLENC
HEALTH ECONOMIST, CEO OF PERFORMA INSTITUTE, BRAZIL
GERARD M LA FORGIA
LEAD HEALTH SPECIALIST, WORLD BANK, WASHINGTON DC
ABSTRACT: A variety of provider payment mechanisms (PPMs) are used in Brazil to direct funds to hospitals. This article
examines their effects on hospital efficiency, costs and quality. Public hospitals funded through the traditional line-item
public budget are the least efficient. Those funded through global budgets and other decentralized budget modalities
perform on a par with private providers funded mainly by private prepaid health plans. Private hospitals that are dependent
on government payments exhibit lower levels of quality. However, the overall effects of PPMs on performance are less than
expected for some groups of hospitals. Factors compromising the impact of PPMs on performance are examined.
Provider payment mechanisms (PPMs) are an essential driver
of performance because health care providers respond to
the incentives embedded in specific payment mechanisms.
Although there is no perfect PPM, a carefully designed payment
system can go a long way toward promoting efficiency, costconsciousness,
and quality.
Brazil has experimented with alternative ways of paying for
hospital services, and debate on the effectiveness of PPMs used
by the government has been ongoing. Nevertheless, despite
modest initiatives to use PPMs to support policy priorities,
payment mechanisms remain essentially an unused policy
instrument in the public sector. The use of payment mechanisms
to influence hospital performance is even less developed in the
private sector.
This article examines PPMs used to pay for hospital services in
Brazil, their embedded incentives and administrative
characteristics, and the effects of both on hospital behaviors.
Drawing on a series of analyses in this article we highlight the
salient findings of the association between PPMs and efficiency,
costs, and quality in Brazilian hospitals. In general, policies to
reform payment mechanisms attempt to improve performance
along one or all of these dimensions.
Payment mechanisms for hospital care in Brazil
Health service purchasers in Brazil (the public system and private
insurance plans) use an array of mechanisms for paying hospitals.
For this discussion, PPMs are classified along two dimensions: by
their use in the public and private sectors and by their pricing
method, and whether the amounts are defined before
(prospective) or after (retrospective) care (Wouters, Bennett, and
Leighton. 1998; Barnum, Kutzin, and Saxenian 1995; and Bitrán
and Yip 1998).
Public sector: Five types of PPMs are used in Brazil’s public
sector and they all are prospective:
✚ Line-item budget. In this traditional form of budget, the
budget is fixed annually and allocated in advance by line-item
categories. Budget formulation is generally based on historical
values. Budgets are managed directly by government through
its Unified Health System (SUS), and hospitals have little
flexibility or managerial autonomy to reallocate resources. This
is the chief public hospital model in Brazil.
✚ Decentralized budget is a variant of the line item budget and
is used in less than 10 percent of public hospitals. Managers
may have a modicum of financial and managerial autonomy,
but usually only for buying consumables such as drugs and
supplies.
✚ Global budget consists of a negotiated global payment
allocated monthly or quarterly. As implemented in Brazil, global
budgets are attached to a management contract with
predefined performance targets (e.g., service volume,
coverage, and quality). Applied in a small by increasing
number of autonomous public hospitals, this model allows
facility managers much more flexibility, and accountability
requirements are more stringent.
✚ Case-based payment. Under this PPM, payment is based on
predefined episodes of care, treatment, or disease, which
include all or most of the individual services or procedures
performed for that episode. Values are in theory based on
24 World Hospitals and Health Services Vol. 47 No. 3

The evolving role of hospitals in health systems: Brazil
average or expected costs, but in
practice have become unaligned
with costs (De Matos, 2002).
Known as the AIH system, this
PPM is a prospective procedurebased
payment mechanism used
by all levels of government to pay
for inpatient care in private
hospitals.
0.2
Private Sector: Two types of PPMs
are used in the private sector:
✚ Prospective fee-for-service
0.1
payment (prepayment). This is a
service-based mechanism by
0
which the cost of individual
services provided is reimbursed. It
is usually based on a previously
agreed fee schedule. This is the
main PPM used by institutional
purchasers in the private sector.
However, large public referral
facilities also maintain contractual
relationships with health insurers
and derive revenue through this
PPM.
✚ Out-of-pocket fee-for-service. For private, uninsured patients,
the main form of payment is out of pocket. Payments are
based on fee schedules, defined, usually prospectively, by
each facility, and are generally much higher than the fees
negotiated between health plans and providers.
Figure 1: Total DEA Efficiency Scores, by PPM, 2002
Total efficiency score (0-1)
Payment Mechanisms and Performance
As displayed in Figure 1, hospitals financed mainly by prospective
prepayment and fee for service displayed higher total efficiency
scores as measured through Data Envelopment Analysis (DEA),
0.456 and 0.437, respectively. All hospitals in these groups are
private. In contrast, hospitals that are dependent on line-item
budget – all public facilities – are the least efficient, displaying
significantly lower DEA scores (0.270). Public hospitals
constituting the decentralized and SUS prospective PPM groups
occupy an intermediate level of efficiency, with DEA scores
approaching the sample’s average (0.341). Importantly, hospitals
paid through global budgets, consisting of public hospitals under
0.5
0.4
0.3
traditional budget
descentral. budget
Source: Dias, Couttolenc and De Matos, 2004
global budget
SUS prospective
Provider payment mechanism
private prepayment
fee-for- service
autonomous management arrangements, achieve scores
approximating those of the privately funded facilities.
We conducted a benchmarking analysis of efficiency indicators
by PPM group and the results more or less confirm the DEA
findings. Bed turnover was highest among private prepayment
hospitals (60), followed by line-item (53) and global (52) budget
facilities. The public prospective fee-for-service and, to a lesser
extent, public global budget groups are the most productive, as
measured by discharges per bed. Line-item and decentralized
budget groups as well as hospitals under prospective prepayment
are the least productive.
Using data from De Matos (2002) we assessed the effect of
PPM on costs. The average procedure cost was computed by
PPM group. However, due to dataset limitations, only four PPMs
were included in the analysis. The unadjusted and case
mix–adjusted findings are displayed in Table 1.
Before adjustment for case mix, the mean procedure cost was
highest for public hospitals (several of them university hospitals)
Table 1: Average Cost of Typical Procedures, by PPM Group, 2001
(Source: De Matos et al., 2002 and Dias; Couttolenc and De Matos, 2004)
Payment mechanism Mean cost unadjusted (R$) Mean CMI Mean cost- adjusted CMI(R$) Mean cost ratioa
Traditional line-item budget 2,924.24 1.105 2,718.40 114.35
Decentralized budget 2,883.72 1.525 2,129.10 77.99
SUS prospective payment 2,037.52 0.851 2,691.25 102.92
Private prospective plans 2,011.29 0.851 2,830.29 100.05
Note: No hospital in the sample belonged to the fee-for-service group. US$ = R$ 2.35 (2001); CMI case-mix index.
a. The mean cost ratio is unweighted, and thus does not equal the ratio of columns 4 and 2.
Sources: De Matos et al., 2002 and Dias; Couttolenc and De Matos, 2004.
World Hospitals and Health Services Vol. 47 No. 3 25

The evolving role of hospitals in health systems: Brazil
under traditional budget and decentralized budget PPMs, and
lowest for private hospitals funded either through SUS prospective
system or private PPMs. The high values observed for public
hospitals, especially those under decentralized budgets, were
expected, because university and teaching hospitals are classified
in that group and overall treat a more severe case load than private
hospitals (as shown by the CMI index, table 1, column 2). After
adjusting for case-mix differences, the relative costs changed
significantly. The decentralized budget group displayed the lowest
procedure costs while hospitals under prospective private
payment displayed the highest, followed by public hospitals under
traditional line-item budgets.
To illustrate the relative costs between hospital groups, a ratio of
the PPM-adjusted mean cost to the overall mean cost was
constructed. This ratio appears in the last column of table 1. The
traditional line-item budget group displayed the highest relative
cost; the decentralized budget group, the lowest. Private
hospitals, whether funded through SUS prospective payment or
private prospective prepayment, showed similar relative costs
around the sample mean. Taken together, results on costs and
relative costs suggest that, once adjusted for case mix, facilities
under traditional budget PPM are relatively costly.
Payment mechanisms must also be judged by how much they
influence quality. Based on the AMS facility survey, we also
examined the effect of PPM on quality. These findings should be
interpreted with caution due to the limitations of the index as
computed from the dataset, as well as the small number of
hospitals in each category.
On average, hospitals funded through traditional and
decentralized budgets achieved slightly higher quality scores
(around 0.5) than those in the other categories. The hospitals
funded through the SUS prospective payment system and fee for
service had the lowest values (around 0.4) while those under
global budgets occupied an intermediate position (0.46). These
results suggest an inverse relation between efficiency and quality,
although this tradeoff appears weak.
Discussion
Public hospitals under traditional line-item budget payment
mechanism are not only the least efficient group, but they also
have higher costs after adjusting for case mix. However, in terms
of structural features of quality, they score the highest. But this is
probably due to higher personnel use. Public hospitals funded
through some decentralized and global budgets are both more
efficient and less costly (after adjustment) than traditional public
hospitals. Autonomous hospitals under global budgets achieve
good scores on efficiency, apparently without compromising
quality. Hospitals depending on SUS prepayments or funded
mostly through fee-for-service payments are efficient but may
provide low-quality care. In the case of hospitals dependent on
government prospective payments, low quality may be due to the
severe resource constraints (because the government pays well
below the cost of most procedures.).
These results are in line with the economic incentives imbedded
in each PPM as described above. The rigidities of the traditional
line-item budget do not encourage efficiency and cost
containment, but flexible, global budgets, associated with
managerial autonomy, do. However, prospective payment
systems based on production (both case-based and fee-forservice),
as implemented in Brazil, appear to promote only limited
incentive for cost control.
As applied in Brazil, PPMs appear to weakly stimulate
performance, and some may actually drive poor performance.
From a policy perspective, we have identified four factors
contributing to the limitations of hospital PPMs in Brazil
Diluted incentives and adverse behaviours
The diversity of the Brazilian hospital sector and the large number
of payers contributes to a multiplicity of PPMs. The typical private
hospital, and an increasing number of public facilities, receives
revenue from several public and private sources. Each funder
applies one or more PPMs. This situation results in diluted and
sometimes conflicting incentives that fail to improve efficiency and
quality.
Absence of cost information
All PPMs are unaligned with underlying costs and therefore do not
reflect resource use. As a result, PPMs do not provide hospitals
with any incentives to use resources efficiently. PPMs are unrelated
to underlying costs partly because there is almost no hard
information on costs in Brazilian hospitals.
Lack of adjustment for case severity.
None of the payment methods used for financing hospitals in
Brazil makes or allows payment adjustment for case severity or
case mix. As in the case of costs, adjusting for case mix is
constrained by the general absence of robust patient information
at facility level. This is related to poor recording in medical charts,
absence of standardized medical practices, and near inexistence
of systematic case review.
Dominance of line-item budgets in public hospitals.
Budgets provide few incentives to raise productivity and quality,
adapt managerial innovations, stimulate managerial flexibility,
decrease excess capacity, or establish a robust information
environment. Because of these limitations, most high-income
countries that once used line-item budgets to pay hospitals have
implemented more sophisticated PPMs such as DRGs, per diem
payment, and global budgets.
Policy implications
To improve the hospital payment system in Brazil, both short-term
and medium- to long-term policy changes are recommended. In
the short term, given the difficulties and time lag involved in
reforming information systems, emphasis should be placed on
improving and upgrading systems such as eliminating
inconsistencies and distortions in the prospective fee-for-service
system, and expanding successful models of payment
mechanisms such as the performance-based global budget
payment system under implementation in the State of Sao Paulo.
In the medium to long term, payment mechanisms should evolve
to incorporate systematic diagnostic and cost information and
migrate toward a DRG-like system, which eventually would be
applied by all institutional payers. ❏
Bernard Couttolenc is a health economist with 20 years of
26 World Hospitals and Health Services Vol. 47 No. 3

The evolving role of hospitals in health systems: Brazil
experience as a hospital manager and consultant for international
organizations in fifteen developing countries. His areas of research
include health care reform, health finance and hospital efficiency. A
former professor at the University of Sao Paulo, Dr Couttolenc is
currently CEO of the Performa Institute, a health policy research
center located in Brazil.
Gerard La Forgia is a Lead Health Specialist at the World Bank,
currently working for the South Asia Region and formerly posted by
the Bank for six years in Brazil. He specializes in health finance and
management in developing countries. He formally was a Research
Associate at the Urban Institute and a Senior Health Specialist at
the Inter-American Development Bank. He has a ScD degree in
Health Service Administration from the University of Pittsburgh.
References
END NOTES:
1. The detailed findings are reported in La Forgia and Couttolenc, 2008.
2. DEA is a method for estimating technical efficiency - the ratio of outputs to inputs used. It
involves the use of linear programming to rank organizations producing goods and services
according to their relative efficiency scores.
3. A case-mix index was computed from the relative costs of individual hospitals to the mean
for each procedure and used to adjust mean costs.
4. Ratios of nearly 100 imply costs near the sample mean.
5. Quality was measured by a quality index based on hospital mortality rate adjusted for case
mix, the ratio of nursing personnel per bed, and the proportion of registered nurses in
nursing personnel. This measure of quality used here, like most other available measures,
can capture only part of the full range of health service quality
6. More than 6,000 public payers (including each of the 5,500 municipalities) and 2,000
private payers are active in the health sector.
7. Such adjustment is important because the cost of care is heavily influenced by individual
case severity and the mix of cases treated by a provider.
Barnum, H., Joseph Kutzin, and Helen Saxenian. 1995. “Incentives and Provider Payment
Methods.” Human Resources Development and Operations Policy Working Paper 51, World
Bank, Washington, DC.
Bitrán, R., and Winnie C. Yip.1998. “A Review of Health Care Provider Payment Reform in
Selected Countries in Asia and Latin America.” Major Applied Research 2 Working Paper 1.
Bethesda, MD: Partnerships for Health Reform, Abt Associates.
De Matos, A., 2002. “Apuração dos custos de Procedimentos hospitalares: Alta e média
complexidade.” Relatório do projeto REFORSUS 003/99. Consultant report for the Ministério
da Saúde, PLANISA, São Paulo, SP.
Dias, L.H. de S., Bernard F. Couttolenc, and Afonso J. de Matos 2004. “Estudo de custos,
eficiência e mecanismos de pagamento, Fase i: Análise de custos de procedimentos
hospitalares. Em busca da excelência: Fortalecendo o desempenho hospitalar no Brasil.”
Consultant report for The World Bank, São Paulo, SP.
IBGE (Instituto Brasileiro de Geografia e Estatística). 2003. Estatísticas da Saúde – Assistência
Médico Sanitária 2002 . Rio de Janeiro: IBGE.
La Forgia, G. and Bernard Couttolenc. 2008. Hospital Performance in Brazil: The Search for
Excellence. Washington DC: The World Bank.
Wouters, A., Sara Bennett, and Charlotte Leighton. 1998. “Provider Payment Methods:
Incentives for Improving Health Care Delivery.” PHR Primer for Policymakers. Bethesda, MD:
Partnerships for Health Reform, Abt Associates.
World Hospitals and Health Services Vol. 47 No. 3 27

The evolving role of hospitals in health systems: Europe
Hospitals and delivery systems:
the need for change
NIGEL EDWARDS
DIRECTOR OF GLOBAL HEALTH REFORM AT KPMG AND SENIOR
FELLOW OF THE KINGS FUND IN LONDON
ABSTRACT: Hospitals across Europe are facing huge pressures and need to change. They are not very well adapted
to deal with these challenges and in many cases the policy frameworks are poorly adapted to help them change.
Hospitals increasingly need to be seen as part of the wider system and need bold and imaginative solutions to
deal with the problems they face.
There is widespread recognition that health care systems
need to change to respond to long term trends in
demography and epidemiology and to changes in medicine
that require very different delivery models from those currently in
use 1-3 . In much of Europe the short term impact of the financial
crisis and the long term challenge of rising costs and shaky
funding sources give the need for change even greater urgency
while at the same time limiting the options that are available to
policy makers by rationing the funds needed for restructuring.
Hospitals are still an important part of the health care system but
their role is changing and being challenged. Increasing amounts
of care traditionally delivered in hospital can be provided as
effectively in settings that are more convenient for patients and
may be less expensive. The growth of non-communicable
diseases (NCDs) and patients with multiple conditions is a
challenge to hospitals that are often insufficiently co-ordinated with
primary care, organised in sharply divided silos based on disease
specialties and which are based on a model of providing short
episodes of care rather than continuity.
The high fixed costs of hospitals means that the economics of
the hospital tend to require it to grow, and this option is
increasingly unavailable, not least because of the effect of the
financial crisis. In many countries there is concern about the
efficiency of hospitals and a major push to reduce lengths of stay,
increase day treatments, improve the use of guidelines, etc. As
well as poor efficiency there are major concerns about quality and
safety which has become a major area of concern over the last
decade.
Hospitals can no long provide all services and in particular a
number of major surgery procedures and specialist care are now
not considered to be safe when done in hospitals that perform
small numbers. This has led to the centralisation of more specialist
activity where there is some evidence that high volumes are
associated with higher quality, this includes cancer surgery,
vascular surgery, neonatal care, trauma, stroke and ST elevated
myocardial infarct. Workforce shortages and restrictions on
working hours are also creating pressures that make the
maintenance of services in small hospitals increasingly difficult 4 .
This is a particular issue in rural areas.
In many countries buildings and equipment are depreciating
faster than the funds for their replacement are being accumulated.
This is a time bomb issue and the shortage of investment capital
in Europe due to the financial crisis is likely to make it worse 5 .
In Central and Eastern Europe (CEE) and the countries of the
former Soviet Union there are a number of additional challenges:
✚ The survival of a number of monoprofile institutions
specialising in TB, infectious diseases and other areas is an
obstacle to the development of high quality multidisciplinary
care.
✚ The very poor state of hospital and other infrastructure
including cases where hospitals have significant problems with
basic utilities
✚ There is very significant over provision of hospital services
generally and in capital cities in particular.
✚ Problems with the workforce migrating to other countries or
the private sector.
The objective in most systems is to develop care that is more
integrated and better co-ordinated in which less care takes place
in hospitals and other institutional settings and where there is a
step change in efficiency and quality.
Responding to the challenge
Hospitals are not very well equipped to deal with these challenges.
Partly this is due to the fact that in the west of Europe they tend to
have a high proportion of fixed costs invested in buildings and
28 World Hospitals and Health Services Vol. 47 No. 3

The evolving role of hospitals in health systems: Europe
equipment. In a number of countries in CEE & CIS the problem is
more about access to the capital that would allow for change
and compounded by very high utility costs. Hospitals also have
a labour force that is much less flexible than in many other
sectors of the economy partly because of the highly inter-related
nature of hospital work and in many cases because of legal,
cultural and regulatory limits on the freedom of managers to
agree flexible local terms and conditions and on whether staff
can be made redundant.
In many countries hospitals have relatively under developed
leadership and management and those responsible for the
strategic oversight and direction of hospitals sometimes lack the
skills, vision or experience to execute this role adequately. It is still
often the case that despite their size and significance hospitals are
still managed by individuals with little formal training in
management, limited support from finance and management
professionals and with appointments that are subject to political
influence. Even in those countries where there Is professional
management the task is difficult and demanding. Costing,
performance management and other information systems are
generally poorly developed as is a culture of accountability.
In many countries there is a very hospital-centric view of health
care at a political level with a bias towards high technology and
tertiary services. Hospitals remain very politically powerful both
nationally and locally and have the ability to block change very
effectively. In countries in CEE where local government is the
owner of the hospitals there is a political dynamic that makes both
efficiency improvement and major reconfiguration more difficult.
Because of the political and economic importance of the hospital,
owners have incentives to resist change but also a limited ability to
hold the hospitals to account for improving quality and efficiency
or challenging them to change their role. The owners are not
sufficiently objective or powerful enough to exercise this power
effectively. At the same time their conflicting responsibilities for a
wide range of other local services has tended to mean that there
is a pattern of chronic under investment in maintenance, buildings
and equipment in a number of countries. Local government in
Denmark, Finland and Sweden have done better with efficiency
improvement and investment but questions about whether they
have sufficient scale to manage strategic change are being asked
and Denmark has already regionalised the oversight of hospitals.
Even where hospitals or other actors in the system are able to
develop strategies there are major challenges that have to be
overcome for strategies to be successfully implemented:
✚ There is difficulty in accessing investment capital in many
countries which has worsened recently.
✚ Implementation expertise is often in short supply.
✚ Successful change in hospitals requires high quality
information on clinical and other activity, financial systems and
well developed management arrangements to ensure that staff
have clear objectives and that they are held to account for
these. As noted above the extent to which these mechanisms
are in place is very variable.
✚ Where major changes are to be made it is particularly
important that staff are fully engaged in supporting and
implementing the change. This is difficult but particularly so in
countries where doctors and other staff have significant
opportunities to work part time in the private system or receive
a large unofficial income.
The changing nature of the demands made on hospitals means
that it is particularly important for them to work closely with other
health and social care services. In many countries, particularly in
Central and Eastern Europe, hospitals have often been poorly
integrated with primary health care and the gatekeeping function
is only partially effective. In those countries where specialist
ambulatory care models exist alongside hospital and primary care
the challenge of care coordination is even greater. The
organisation of hospitals on clinical silos defined by the disciplines
of the doctors, rather than the often complex, multiple and illdefined
needs of the patient, tends to exacerbate this. The
separation of mental health services from both primary and
hospital care is a particular concern as increasingly patients with
long term conditions and frail older people admitted to hospital are
likely to have mental health co-morbidities.
While there has been significant development of the family
doctor system in many countries in Central and Eastern Europe
and the CIS there is still more to do to develop a really effective
gatekeeping system. In many countries primary care is
fragmented, has limited resources and has poor access to
diagnostics and specialist opinion. This is a significant obstacle to
co-ordinated care and leaves the hospital as the provider of last,
and often first, resort.
Issues with policy frameworks
The wider policy framework is not always supportive of the
changes that are required. Although many countries have now
moved away from historically based and centrally set line item
budgets to a variety of activity based payment methods there is
still much to do. For many chronic conditions payment systems
that re-enforce an episodic model of care and that incentivise
additional activity are not appropriate but progress towards more
bundled payment has been slow.
DRG based payment methods may encourage improved
efficiency but they are not particularly powerful as mechanisms to
change the shape of the hospital system. This requires some
decisions to be taken at a political level, by the payers or by the
providers themselves. For all the reasons listed above this has
proven to be difficult.
Often not enough is done to articulate the vision for the future
role of the hospital or the shape of the wider delivery system.
Some countries have developed hospital masterplans but these
tend to focus on the distribution of facilities. Sometimes there is
even a lack of acknowledgement that there are problems. There
may not even be a clear locus for policy leadership on health care
delivery systems. Many CIS countries have made surprisingly slow
progress in developing policy that will drive significant change.
The response to this
It is fashionable to predict the end of the hospital and yet they have
proven to be more robust than most prophets have expected.
This does not mean that they do not need to change radically.
Firstly, it is time to talk about the whole delivery system not just
hospitals. It is now impossible to reform hospitals without also
changing primary care, specialist management of chronic disease
and long term and social care. Increasingly their interface with
mental health services also need to be considered. It is alsotime
World Hospitals and Health Services Vol. 47 No. 3 29

The evolving role of hospitals in health systems: Europe
Box 1: UK experience
In the UK the pressures to centralize care, financial pressures
and workforce shortages are raising questions over the
financial and clinical viability of a number of smaller hospitals.
Staffing obstetric and paediatric units, the availability of staff to
support emergency surgery and emergency units is increasingly
challenging. This is leading to mergers and proposals for
closures and partial closures. So far it does not seem to have
led to any very radical approaches to the redesign of the
traditional hospital and the assumption appears to be that
following rationalisation the remaining services are just bigger.
Some experimentation with home care and decentralised
care has taken place but this is not usually on a scale to prevent
a significant change in the number of patients needing to
attend hospitals. For some specialties network models have
provided a solution to the problem of how to standardise care
between providers and maintain services where a standalone
staff would be unsustainable. However, few of the assertions
and evidence that is relied on in making these assertions and
drawing up plans to address them appears to be based on a
robust research literature.
Over the last 6-7 years many providers have become
autonomous Foundation Hospitals in an attempt to break the
hold of central government and encourage more entrepreneurial
behaviour. There has been some partial success in this but still
50% of hospitals have not made this transition.
that the rigid silos between different specialisms within the hospital
are broken down to ensure that there can be multidisciplinary care
and on this basis the stand-alone infectious diseases hospital
seems to be a thing of the past. There is an emerging argument
from authorities such as Michael Porter and Clayton Christensen
that suggests that hospitals and the wider health care system are
made up of models that are grouped together more for reasons of
history than business logic 6,7 . They argue that the interaction of
these very different business models – factory type elective care
and the much more uncertain and variable emergency medicine
means that the hospital is not optimised for most of the patients it
sees and creates huge inefficiency. This suggests a far more
radical change in the way hospitals are organised.
Managing these large and important parts of the health system
cannot be done from the centre and there is a trend in many
countries towards the devolution of power to local hospital
managers and owners. In some cases this has been accompanied
by changes in the legal status and ownership of the hospital and
the growth in more transparent reporting of performance. This
reflects a growing interest in ensuring organisations are well
managed and much more emphasis on transparency and a
culture of accountability which is potentially a powerful source of
change.
Improving the internal efficiency of hospitals, focusing on making
care systematic and organised along pathways that span
organisational boundaries is going to be increasingly important.
The application of redesign and production engineering
approaches such as Lean is surprisingly slow but does appear to
be an effective approach. Ensuring that the training of clinical staff,
the payment systems and the regulatory arrangements support
these changes is going to be particularly important.
Policy makers need to be clear what they want from hospitals,
understand that hospitals, the patients they serve and the
diseases they treat are very different from what has gone before
and that major change will be required. Politicians will find this
difficult and so it is now time for clinicians and managers to take a
lead, apply new ways of thinking to transforming how the hospital
operates internally, to improve co-ordination with other services
and radically change the wider system beyond the hospital’s
doors. We need a really compelling and powerful story about how
care could be different and the new role that hospitals will play in
that. There needs to be capital to allow them to change and many
people attached to old models need to be prepared to abandon
them. ❏
Acknowledgements
This article is extracted from a study performed for the WHO
Regional Office for Europe
Nigel Edwards is Director of Global Health Reform at KPMG and a
Senior Fellow of the Kings Fund in London. He is an Honorary
visiting Professor at the London School of Hygiene and Tropical
Medicine. He has recently been working with the WHO Regional
Office for Europe on hospitals and delivery systems
References
1.
Rechel B, Wright S. Edwards N DowdeswellB and McKee M. Investing in hospitals of the
future European Observatory for Health Systems and Policies.
http://www.euro.who.int/__data/assets/pdf_file/0009/98406/E92354.pdf
2.
European Observatory on Health Systems and Policies: Hospitals in a changing Europe
http://www.euro.who.int/en/home/projects/observatory/publications/policybriefs/observatory-policy-briefs/hospitals-in-a-changing-europe
3.
Spurgeon P, Cooke M, Fulop N, Walters R, West P, 6 P, Barwell F, Mazelan P (2010).
Evaluating Models of Service Delivery: Reconfiguration principle.National Institute for Health
Research Service Delivery and Organisation programme. London: HMSO.
4.
Imison C. Reconfiguring hospital services.The King’s Fund
2011.http://www.kingsfund.org.uk/publications/articles/nhs_reconfiguration.html
5.
Rechel et al op cite.
6.
Clayton M. Christensen, Jerome H. Grossman, and Jason Hwang. The Innovator's
Prescription: A Disruptive Solution for Health Care. New York, McGraw-Hill, 2009.
7.
Porter M, Tiesberg E Redefining Healthcare. Harvard Business School Press; 2006
8.
Richard B. Saltman, Antonio Durán, Hans F.W. Dubois Governing Public Hospitals: Reform
strategies and the movement towards institutional autonomy European Observatory on
Health Systems and Policies (Forthcoming)
30 World Hospitals and Health Services Vol. 47 No. 3

The evolving role of hospitals in health systems: Australia
Better than a crystal ball? Using
simulation to foresee emerging issues
in the Australian Healthcare System
PATRICK BOLTON
NATIONAL VICE-PRESIDENT OF THE AUSTRALIAN HOSPITALS
AND HEALTHCARE ASSOCIATION (AHHA), DIRECTOR OF
CLINICAL SERVICES AT PRINCE OF WALES HOSPITAL SYDNEY
PRUE POWER
EXECUTIVE DIRECTOR OF THE AUSTRALIAN HEALTHCARE AND
HOSPITALS ASSOCIATION (AHHA)
ABSTRACT: A change in the national government of Australia in 2007 lead to a process of review and reform in healthcare
which is now being implemented. The Australian Healthcare and Hospitals Association (AHHA) ran a simulation exercise
to model the likely impact of the planned reforms.
This paper describes the background to these changes, the process of consultation and implementation of the reforms,
and the results of the simulation exercise. The process identified the risks inherent in the reform and the need to address
long term structural issues in the Australian health care system in order to ensure optimal patient-centred care.
Labor, a social democratic political party, was elected to
power in Australia in 2007 after an 11 year rule by Liberal, a
conservative party. The newly elected government was
perceived to have a mandate for change which included health
care and has recently negotiated a new funding model for the
health system after four years of discussion and debate. The
Australian Health care and Hospitals Association (AHHA) engaged
leading policy makers and service providers in a simulation
exercise to explore the likely results of these changes.
This paper starts by describing the Australian health care
system as it has operated for the last three decades and the
perceived problems with it. The history and nature of the reforms
is then discussed. It then describes the application of a method of
modelling by simulation to explore the possible consequences of
the planned reforms.
The Australian health care system
In 2007-8 Australia spent 9.1% of GDP on health care, just over
the OECD median of 8.9% 1 . Government (Commonwealth and
states) funded almost 70%, and hospitals consumed more than
one-third of the total. Hospital admissions rose by 37% in the
decade to 2008. A key concern for funders is the sustainability of
the system in the face of this growing demand, which is the critical
driver for reform 2 .
The Commonwealth government funds Medicare, the public
insurance scheme for outpatient generalist and specialist medical
services, and subsidises the cost of most prescription
medications. The State governments, partly subsidised through
direct Commonwealth grants, fund public hospitals. Public
hospital care is free, while patients contribute to the cost of a
majority of outpatient medical services. This dichotomy in
responsibility for service provision lead to gaps in continuity of care
and encouraged cost-shifting between funders, with consequent
inefficiency and inequity 2 .
Australians enjoy good health 1 . Their levels of health generally
compare favourably with those of other OECD nations. Their life
expectancy is the highest of OECD nations, although they rank
20th in infant mortality. There remain gaps in access to health
services, particularly for Indigenous and rural Australians. These
too provide a stimulus for reform 2 .
The reforms
The Labor Government under Prime Minster Kevin Rudd
appointed a panel of senior health practitioners, health policy
analysts and former politicians to the National Health and
Hospitals Reform Commission within a year of winning office in
2007. Their terms of reference focused on improved efficiency
through greater integration of health services, particularly in aged
care, increased disease prevention, and better chronic disease
management; improved access, particularly in rural areas and for
Aboriginal people; and a sustainable health workforce. The
Commission tabled its final report in June 2009 2 .
The Commission made over one hundred recommendations.
These included improved access to dental care – hitherto
excluded from Medicare; improved access to mental health; and
greater investment in information technology in support of
improved use of data. A controversial proposal, designed to end
the split in responsibility for health services between the
Commonwealth and States for ambulatory and hospital care
respectively, was to be operationalised through compulsory,
privately administered health insurance underwritten by a base
level of risk adjusted public subsidy. The key recommendations for
hospitals were national performance targets for timely care
delivery, and a standardised “efficient price” for health services.
World Hospitals and Health Services Vol. 47 No. 3 31

The evolving role of hospitals in health systems: Australia
When the government was elected in 2007, its mandate for
reform was strengthened by the fact that the Labor Party was in
government Federally and in all six major States. By the time the
Commission reported in 2009, Labor had lost office in Victoria –
the second largest State, and was to lose government in New
South Wales – the largest State – and Western Australia shortly
thereafter. Prime Minister Rudd sought to fund greater
Commonwealth control of, and responsibility for, the health
system, by retaining State income raised through a national goods
and service tax. The States rejected this model. Rudd’s electoral
popularity fell to levels unprecedented for an Australian Prime
Minister in their first term in office concurrently with this, and he
was replaced by Julia Gillard.
Labor won the following election at the end of 2010 by the
narrowest of margins, and was left negotiating its reform agenda
as a minority government. In February 2011 the Council of
Australian Governments (COAG - the peak body representing the
Commonwealth and the States) published a Communiqué in
which they agreed “to work in partnership on National Health
Reforms to deliver a better deal for patients and secure the longterm
sustainability of Australia’s health system”. 4 The headline goal
of the reforms is “a nationally unified and locally controlled health
system that will ensure future generations of Australians enjoy
world class, universally accessible health care”.
The reforms implement many of the Commission's
recommendations, but in a less complete, and arguably less
coordinated, fashion than the Commission envisaged. Critically,
there is no single funder and no clear driver to integrated health
services. Hospital performance targets based on the timeliness of
care have been introduced. Efficiency is encouraged by the setting
of a benchmarked “efficient price” for hospital services by an
Independent Hospital Pricing Authority. A national episode funding
mechanism is to be introduced which has the potential to become
the major mechanism by which hospital service provision is
influenced and coordinated at a policy level. The States continue
to manage hospital services, while the Commonwealth continues
to subsidise these and is responsible for community based
ambulatory care. The stated objective of greater local control of
health services is sought through the creation of health service
boards with the usual corporate commercial responsibilities to
govern both Local Hospital Networks (LHNs) and “Medicare
Locals” (MLs). MLs have been established from existing
geographically based Divisions of General Practice, with the
intention that they should integrate all community health care,
including non-medical services, and negotiate with hospitals to
better integrate services between the hospital and community.
There is some suggestion that they may become purchasing and
commissioning agencies, but this has not been formalised.
The Simulation
The Simulation process was based on the United Kingdom’s
National Health Service / Kings Fund ‘Rubber Windmill’ 3 exercise.
It was designed to reflect the system during and after
implementation of the reforms and focused on the interactions
between the participants in three scenarios over different time
periods at 18, 36 and 60 months into the future.
This method offered a safe environment where the dynamics of
the new system could be explored and provided advance insight
into some of the challenges and opportunities that the reforms are
The reforms implement many of the
Commission’s recommendations, but
in a less complete, and arguably less
coordinated, fashion than the
Commission envisaged
likely to generate. It drew directly on the experience and
judgement of the participants who played their own roles as
politicians, senior government officials, clinicians, managers, policy
shapers, consumers and journalists. Participants benefited from
the Simulation in their personal learning and understanding of how
best to respond to the reforms in their professional context.
The outcomes
The Simulation generated a number of hypotheses or system
descriptions in respect of the environment created by the health
care reforms as COAG has developed them to date. These are set
out in the following paragraphs.
Improvement in clinical services and consumer experience will
depend on MLs and LHNs working together to deliver integrated
services across boundaries. It remains unclear what financial or
other incentives exist to facilitate this. The role of MLs and the
mechanisms through which they are to achieve their objectives
remain unclear. In the simulation, LHNs became increasingly
focussed on managing internal functions in response to financial
pressure, in preference to developing better integrated services
with the MLs. Health services in poorly resourced locations, such
as rural and outer metropolitan regions, struggled to engage in
integration and the reforms in general.
The new Commonwealth-State financing arrangements are a
central feature of the reforms. The Simulation was designed to test
the Independent Hospital Pricing Authority’s role in setting the
“efficient price” for services. It identified a lack of clarity about how
the efficient price would be set. Traditional funding mechanisms,
such as fee-for-service, are unlikely to provide adequate incentives
for multi-professional team care involving a range of services. The
price setting model has the potential to determine whether and
what model of services are provided. It offers a mechanism for
rationing hospital services which has been at best implicit in the
Australian health care system hitherto. It is therefore critical to
determining the future role of hospitals in Australia.
Care will be required to ensure that funding mechanisms do not
simply maintain the status quo, and that new models are tested to
determine which health services are best provided in what setting.
The new funding model may be too rigid if it has no capacity to
support the allocation of resources which allow the substitution of
more efficient services for less efficient services. There is a danger
that this aspect of the reforms will lock in existing inefficient
practice, rather than providing an environment which fosters the
development of innovation and testing of more efficient models of
service delivery.
The Simulation noted the potential for competition and
duplication between the various new data and regulatory
authorities. These are the National Health Performance Agency,
32 World Hospitals and Health Services Vol. 47 No. 3

The evolving role of hospitals in health systems: Australia
the Australian Institute of Health and Welfare, the Australian
Commission on Safety and Quality in Australia and the COAG
Reform Council. Consideration was also given to the activities of
the National E-Health Transition Authority (NeHTA) and its role in
supporting collection of data. NeHTA will determine health data
definitions and data sets in electronic patient records. These need
to be coordinated with data and regulatory activities conducted by
the other agencies.
The extent to which the private sector will be governed by the
various regulatory and funding authorities is unclear.
References
1.
Australian Institute of Health and Welfare 2010. Australia’s health 2010. Australia’s health
series no. 12. Cat. no. AUS 122. Canberra: AIHW, accessed at
http://www.aihw.gov.au/publication-detail/?id=6442468376&tab=2, 16 August, 2011
2.
National Health and Hospitals Reform Commission. A Healthier Future For All Australians –
Final Report of the National Health and Hospitals Reform Commission. Commonwealth of
Australia, 2009
3.
King’s Fund. Windmill 2009 – NHS response to the financial storm. King’s Fund, 2009,
http://www.kingsfund.org.uk/publications/windmill_2009.html, accessed 21 August 2011
4.
Council of Australian Governments, February 2011, accessed at
http://www.coag.gov.au/coag_meeting_outcomes/2011-02-
13/docs/communique_20110213.rtf, 21 August 2011.
Conclusion
This Simulation highlighted the good-will and potential that exists
to deliver improved health care. Equally, it identified the importance
of the implementation process and the creation of the right
incentives. There remains a high level of uncertainty among senior
health leaders about the basic implications of the government's
reform agenda and the complexity of the working arrangements.
Participant observations summarise the challenges which lie
ahead:
A health worker participant observed:
The Simulation’s early phases gave us all insight into how
powerful is the old “State vs Commonwealth” competitive culture
within the health system, and how this has the potential to derail
any genuine reform initiatives. Equally, the Simulation later revealed
how effectively all key elements of the system can work together
when State and Commonwealth leaders and bureaucrats decide
to work positively towards change with a renewed focus on
consumers and providers – and not traditional internally-focused
pursuits.
One of the consumer participants said:
The way events unfolded on the day were actually quite
extraordinary and shone the spotlight on Consumers and
Consumer Centred Care principles being key to the solutions for
healthcare. The outcome of the day highlighted the need for the
real world system implementation to initiate new ways to ensure a
collaborative approach takes place right at the start of any process
and the direction driven in partnership with Consumers at all levels
of healthcare. ❏
Patrick Bolton is National Vice-president of the Australian Hospitals
and Healthcare Association (AHHA), Director of Clinical Services at
Prince of Wales Hospital Sydney, and has broad experience in
management and services delivery in the Australian healthcare
system.
Prue Power is Executive Director of the Australian Healthcare and
Hospitals Association (AHHA). Previous roles have included
Director of General Practice with the Australian Medical Association
and Adviser to the Commonwealth Minister for Health. Prue has
served on a number of Boards, including 5 years on the ACT Health
& Community Service Board.
World Hospitals and Health Services Vol. 47 No. 3 33

The evolving role of hospitals in health systems: Switzerland
Reshuffling the pack in the
Swiss hospital market
BERNARD WEGMÜLLER
EXECUTIVE DIRECTOR OF THE SWISS HOSPITAL ASSOCIATION
H+
MARTIN BIENLEIN
HEAD OF POLITICS OF THE SWISS HOSPITAL ASSOCIATION, H+.
ABSTRACT: Swiss hospital face two major changes: one is the introduction of DRG as the currency for payment and the other
one is the shortage of personnel due to demographic changes. They will do so by strengthening their accounting systems to
be able to calculate costs per patient. First steps to attract new personnel are taken within the new professional educational
system. A third change, the evolving landscape of social health insurance companies, is hard to predict.
Integrated care is on the top of the political agenda. However, the
Swiss hospitals have other priorities these days. They have to
reorganize their core business and position themselves in a
national hospital market with new rules.
The social security act on health care dominates the Swiss
health care system. In order to reduce costs and provide better
services for patients, the parliament discusses new regulations on
managed or integrated care. The legislative outcome is open, and
the effects on the Swiss hospitals are even less predictable.
Although some hospitals have integrated care procedures for
certain illnesses, there is currently no massive trend towards
integrated care models within the Swiss hospital market or the
health care market as a whole.
Five tasks for Swiss hospitals
Instead, the hospitals try to adapt to and to implement legal
regulations which have already been decided and will come to
effect on the 1st of January 2012. In 2007, the Swiss Parliament
has revised the hospital financing by demanding a national DRG
system for in patient services combined with a financial
benchmarking among hospitals. The aim is to bring about
transparency in medical service tariffs. The partners in the health
care system (health insurances, public entities and hospitals) have
decided to introduce Swiss DRG, a DRG system derived from the
German G-DRGs. It will take several years until we see the effects
on the Swiss hospital system, i.e. which hospitals will survive and
which will not. The challenges and tasks of each hospital are as a
consequence manifold. Firstly, they have to introduce the
necessary means of data collection, codification and billing.
Secondly, they have to enable themselves to calculate the cost of
the average patient per DRG and, based on that, calculate
reasonable prices for their services. Thirdly, hospitals might want
to make the treatment procedures more effective, especially by
cutting waiting time and reducing length of stay. Fourthly, they
might focus their services by reducing the number of diagnoses
and treatments offered. Fifthly, small and medium hospitals in
particular will tend to merge to bigger entities. Hospitals with a
public ownership have undergone such processes already in the
decade before. In 18 out of 26 cantons (political entities), public
hospitals are a single legal entity, often situated in different
locations. Private clinics are now following this path. So far, there
are two nationwide private hospital groups with 14 and nine
locations, respectively.
Since the prices for the DRGs have not been negotiated yet,
even hospitals which are economically up to date cannot be sure
if they will survive in their current form and with the range of
services offered so far. This uncertainty brings a lot of unease in
the hospital system,even though most other parameters within the
health care system, even remain stable.
Lower priority for an overall vision
In such periods of perturbation and turmoil, attention towards the
health care system as a whole is rare. The focus of the hospital
management is currently turned inside, towards the functioning of
the own enterprise. It seems as if visions and leadership can be
mastered best with traditional business administration means
such as strategy formulation and implementation, human
resources or process orientation. Traditionally, Swiss hospitals are
well equipped and fast in implementing new technologies. This is
a good precondition for coping with the challenges of the on-going
change process.
More personnel in the long run
Like most European countries, Switzerland faces an ageing work
force as well as ageing patients. This leads to a paradox: getting
short of employees when you need them the most. Swiss
hospitals have not been forced yet to change their recruiting
strategy fundamentally. There are four good reasons for this: firstly,
34 World Hospitals and Health Services Vol. 47 No. 3

The evolving role of hospitals in health systems: Switzerland
they limit the work task of care professionals to care and outplace
non-care work to other employees, such as making beds or
serving food. Secondly, hospitals and clinics offer a new
professional education in care beginning directly after obligatory
school, at the age of 16. Young employees generally work under
the mandate of experienced nurses, rather than replacing them.
Thirdly, the jobs which hospitals and clinics offer are usually more
attractive compared to long term care institutions. Thus they are
forced less to seek new workforce on the market. Fourthly,
increasing the effectiveness of hospitals and clinics, as seen
above, may lead to reducing staff, which can be reinserted for the
rising number of patients in other departments or houses.
Nevertheless,it is to assume that the combination of aging
workforce and aging patients will lead Swiss hospitals to take
more action in recruiting personnel in the near future.
where he occupied various functions. Bernhard Wegmüller has
PhD in Biochemistry and an MBA.
Martin Bienlein Bienlein is Head of Politics of the Swiss Hospital
association, H+. He has joined H+ in 2002. Martin Bienlein majored
in political science in Bern, Switzerland. He graduated from High
School in Hamburg, Germany, where he was born.
Uncertain role for insurance companies
Today there is a clear role distinction between hospitals as service
providers on the one hand and insurance companies as payers on
the other hand. A systematic cooperation between the two actors
to the benefit of the patients is so far missing. With the introduction
of managed care, the role of the insurers might be subject to
change. In what direction this change will go and how strong it will
be, depends on the legal framework that the Parliament is ready
to give. Debates on that matter have been heavy, especially in a
time of rising insurance premiums. Insurance companies up to
now have shown themselves incapable to contain costs. Instead,
they pass them on to the insured.
The role of insurance companies might also change when in the
near future the number of insurance companies drops from today
80, leaving half a dozen or dozen nationwide insurance companies
behind. The fewer they are, the more important is their role. The
bigger the share of an insurance company among the patients of
one hospital the greater is their potential impact on the service
they are paying. When today an insurance company has a share
of 10% of patients, their impact is not considerable, because they
have limited means to deviate their patients to another hospital. In
any case the effect would be limited, as 90% of the patients in that
hospital are insured by other companies.When the share rises to
40 or 60%, the negotiation between the insurance company and
a hospital will change naturally. Payment conditions are vital to
hospitals.
Conclusion
By using traditional entrepreneurial means, Swiss hospitals
actively adapt to the new tariff system Swiss DRG. And they will
be even more active in the field of human resources in the near
future, to meet the challenges of an aging society. However, it is
not foreseeable whether Swiss hospitals will seek a more active
and systematic role within the integrated care or the health care
system as a whole. Another major change comes from the
insurance companies finding their new role in the managed care
and a consolidated insurance market. ❏
Bernhard Wegmüller has been Executive Director of the Swiss
Hospital Association H+ since 2004. He joined the association of
the public and private hospitals and clinics in Switzerland in 2001.
From 1994 to 2001, he worked for a pharmaceutical company,
World Hospitals and Health Services Vol. 47 No. 3 35

The evolving role of hospitals in health systems: Nigeria
The evolving roles of hospitals in
health systems: the Lagos –
Nigeria example
DR RAFIAT OLUFUNMILAYO OLATUNJI
CONSULTANT HAEMATOLOGIST WITH BIAS FOR TRANSFUSION
MEDICINE, PIONEER PERMANENT SECRETARY OF THE LAGOS
STATE HEALTH SERVICE COMMISSION IN NIGERIA
DR OLUFEMI M OMOLOLU
CONSULTANT OBSTETRICIAN GYNAECOLOGIST AND DIRECTOR
OF CLINICAL SERVICES AT THE LAGOS ISLAND MATERNITY
HOSPITAL
ABSTRACT: With the revision of the definitions of health systems and the expectations of the public there is a
need to reassess the roles of hospitals. Hospitals remain the centre of health care services and they face lots of
challenges in service delivery. Lagos State in Nigeria has analyzed her peculiar circumstances and formulated a
Health Service Reform law. This law seeks to restructure the State’s health system with an emphasis on improving
the functioning of the hospitals. This article highlights the roles of hospitals in general with an insight into how
the Health Service Reforms seek to improve Lagos hospitals and health system.
The term “health system” encompasses the personnel,
institutions, commodities, information, financing and
governance strategies that support the delivery of
prevention and treatment services. The main objectives of a health
system are to respond to people’s needs and expectations by
providing services in a fair and equitable manner. 1
The World Health Organization defines a health system as “all
the activities whose primary purpose is to promote, restore, or
maintain health.” 2, 3 The World Bank defines health systems more
broadly to include factors interrelated to health, such as poverty,
education, infrastructure and the broader social and political
environment. 4
These revisions in the definitions of health systems have also
redefined the different approaches to functioning of health
systems.
Hospitals have long been the centre of health care in
communities worldwide. Most citizens see their community
hospital as the place to visit when sick or in need of emergency
care. Most do not see it as a place for ongoing health, focusing on
treating disease rather than preventing disease. But that is quickly
changing. With a focus on developing community-based
programs, investments in continuous process improvement, and
integrating the appropriate information technology into the caredelivery
process, hospitals and health centres can become
centres for community health. The goal is to maximize health by
offering programs on wellness, prevention, early detection, and
ongoing health management.
Today, hospitals and health systems are on the frontlines of this
broken system. They persevere every day in the face of mounting
challenges such as:
✚ Uncompensated care for patients without insurance;
✚ Perpetually rising costs;
✚ Inability to hire enough nurses and other skilled providers;
✚ Perverse payment models that encourage waste and
inefficiency;
✚ Growing demands of an aging population;
✚ Overcrowded emergency rooms;
✚ Lack of broad technology adoption and, therefore, system
wide interoperability;
✚ Rising liability costs.
These challenges are global but more so in Africa which
continues to struggle to keep up with the developed world. This
was recognized at the WHO Regional Committee for Africa
meeting on Strengthening the role of hospitals in national health
systems in the African Region in 2003. At that meeting it was
resolved that there was a conviction of the importance of fully
functional hospitals as integral parts of national health systems in
the attainment of health for all, including their contribution to
retaining suitably qualified health personnel with a need to
reorientation and restructuring of hospitals based on primary
health care and develop strategies for improving quality of care in
health care institutions in the African Region 5 .
In Nigeria health care provision is a concurrent responsibility of
the three tiers of government in the country. 6 However, because
Nigeria operates a mixed economy, private providers of health
care have a visible role to play in health care delivery. The Federal
Government’s role is mostly limited to coordinating the affairs of
the University Teaching Hospitals, while the state government
manages the various General Hospitals and the local government
focus on dispensaries. There are numerous problems with the
health system in Nigeria as evidenced in the WHO country
36 World Hospitals and Health Services Vol. 47 No. 3

The evolving role of hospitals in health systems: Nigeria
cooperation strategy report 2008-2013 7 . As the major source of
health care delivery, there is thus a need for a change that requires
hospitals to embrace new values, visions, goals, and metrics of
success.
Lagos state the commercial capital of Nigeria with a population
of 18 million people was caught in this web of problems and
sought to tackle them head on. This led to the signing into Law of
the Health Sector Reform Bill 9 which ushered in a new era in
Health care service delivery in the public owned hospitals in Lagos
State in 2004. This brought about the redefinition of stewardship
role of government and provided for autonomy of the hospital
units which led to drastic improvement of hospital functioning
thus aligning the state health care delivery system with what
obtains in the 21st century and by extension provision of better
service to the community. The objectives of the health sector
reforms were to establish a state health system which:
✚ Encompasses public and private providers of health;
✚ Provides the population of the state with the best possible
health service that available resources can afford;
✚ Sets out the rights and duties of health care providers,
workers, establishments and users;
✚ Provide uniformity in respect of health service delivery across
the state.
Some of the strategies of the reforms are:
✚ Re-organisation of the Health care system.
✚ Redefinition of the stewardship role of the Ministry of Health.
✚ Decentralization of Health management board (which was a
central body responsible for all the needs of the hospitals
ranging from funding to staffing to procurement etc) and the
creation of a Health service commission which would focus
mainly on management of Human Resource for Health.
✚ Revitalization of the primary health care system.
✚ Promoting Public-Private partnership.
✚ Enhancing the management expertise of health care
managers.
✚ Encouraging alternative sources of financing for the health
sector.
✚ Establishment of a regulatory agency to ensure minimum
standard of health care service is provided in all health
institutions.
✚ Enhancing the technological capacity through improvement of
the HMIS
The new arrangement entails that the Ministry of Health takes
up the stewardship role with regard to policy formulation, health
program derivation and implementation, and the Health Service
Commission deals with HRM matters while hospitals through the
granted autonomy anchors day-to-day activities. The later is
carried out through the Hospitals Governing Boards and Hospitals
Management Committee.
The roles of hospitals can be viewed in the following regards:
Role to patients
Patients come to the hospitals expecting to receive care. This
used to be simply the case but now an enlightened people come
hoping to receive not just care but affordable good quality care.
Delivery of safe, efficient, and effective care is now essential. It is
thus necessary that hospitals pay attention to the quality of care
provided by the hospital staff and the support services. This also
requires investing in cutting-edge technology, embracing new
models and processes of delivering care, and using care
guidelines based on evidence. The attitudes of hospital staff must
be at its best as this alone is one of the key areas of perceived
quality of health care. Supporting units must also be established
where patients can be adequately counseled on their conditions
and given health promotion tips which will help to prevent or limit
disease. The Hospital Governing Board is expected to set up
agendas towards achieving these. This has been done in Europe
as seen in the proceedings of the 2nd International Conference on
Health Promoting Hospitals held in Padova Italy 8 where various
health promoting activities in different pilot hospitals were
discussed. In Lagos Nigeria there has been a failure of the Primary
Healthcare System and Health Reform Law sought to correct this
by establishing a State Primary Health Care Board and a Local
Government Health Authority to deal with Primary health care
issues and thus free up the secondary and tertiary hospitals to
perform their specific roles.
Role of hospitals to hospital staff
Often too much focus is given to patients while little attention is
paid to hospital staff but studies have shown that the hospital staff
plays a key role in the quality of services provided as they will need
to implement any change that can help improve health care
delivery. This starts from the leadership within the hospitals to the
lowermost cadre of staff. The leadership of hospitals in Lagos
State have always been medical doctors with very sound medical
education and experience but limited leadership and management
skills. Some even get to top management positions by
“promotion”. Leadership and management training is very
essential for hospitals to be well run and The Health Reform Law
addressed this issue. In line with this the Lagos State Health
Reform Law stated that hospitals must have a Hospital
Management Committee comprising of all heads of departments
which must meet monthly and partake in the administrative
functioning of the hospital. Continuous training and re-training of
all hospital staff which is very essential is undertaken by the Health
Service Commission. This involves not just professional training
but also administrative, equipment maintenance, attitudinal and
use of protocols and guidelines as well as appropriate staffing and
remuneration of workers. In all there is the need to continuously
create an engaged, motivated, and passionate workforce. This
requires internal changes to how hospitals organize, educate,
support, and compensate their employees, from administrative
staff to nurses to executives to physicians.
Role to the community
There is a need for hospitals to reach out to the community it
serves. Hospitals are sometimes seen as a place no one wants to
visit as it is truly filled with sickness and gloom. Hospitals could
help prevent this bleak picture through health promotion activities
which will be another reason for people to visit hospitals.
Screening programmes, well being clinics, diet clinics are
examples of health promotion clinics that can put hospitals in a
good light and change the way they are perceived. Hospitals must
become centres of community health. This requires that they
World Hospitals and Health Services Vol. 47 No. 3 37

The evolving role of hospitals in health systems: Nigeria
move from an acute-based, volume-driven model to one that
maximizes health, wellness, prevention, early detection, and
ongoing health management.
The issue of quality care cannot be over emphasized. In this
regard hospitals must embrace production models of delivery and
efficiency to improve outcomes. This requires incorporating proven
systems of production like LEAN Six Sigma into all aspects of
clinical operations. With this hospitals can build a true consumerfocused
organization with a genuine, core focus on the patient’s
experience and well-being. This requires building a model that
creates a culture of customer service and deploys the appropriate
tools and technologies to engage their patients.
The Lagos State Health Sector Reforms sought to address
these roles and functioning of the hospitals. Each State Hospital
has its own Governing Board amongst whose functions are:
✚ Setting out targets in line with the overall objectives of setting
up the hospital(s) and taking due cognisance of government
policy directives as provided by the Commissioner for Health,
in respect of economic, financial, operational and
administrative programs;
✚ Measuring performance against set targets;
✚ Implementing broad policy measures on hospital and health
care development plants;
✚ Supervising and monitoring management committees to
ensure that targets are achieved;
✚ Ensuring co-ordination and integration of various hospital
services within its jurisdiction;
✚ Approving expenditure up to a maximum amount as approved
by the Governor for each hospital, and delegating as
appropriate, any portion of that power to the Hospitals
Management Committee;
✚ Considering and accommodating private sector participation
in clinical and non-clinical support services in line with
approved guidelines issued by the Ministry, e.g. Pharmacy,
Radiology, Laboratory, Mortuary and any service(s) that may
be necessary for the hospital.
facilities within the state, public or private, perform within a given
standard of health care delivery.
Since the passing of the Health Sector Reform into law in 2004
there has been improvements in the roles hospitals play in health
care delivery. Despite the fact that the law is somewhat in its
infancy stage, its impact on the Health System In Lagos State is
already obvious as it has redefined the roles and functioning of
hospitals within the State. ❏
Dr Olatunji is a Consultant Haematologist with bias for Transfusion
Medicine and the pioneer Permanent Secretary of the Lagos State
Health Service Commission in Nigeria. She is an advocate of reform
in the Health Sector and is currently at the vanguard of its
implementation.
Dr Omololu is a Consultant Obstetrician Gynaecologist and the
Director of Clinical Services at the Lagos Island Maternity Hospital.
He is also the Head of the Quality Unit of the hospital.
References
1.
World Health Organization. 2000 World health report 2000: health systems: improving
performance. Geneva: WHO. Available from:www.who.int/whr/2000/en/index.html
2.
WHO. 2008. Maximizing positive synergies between health systems and global health
initiatives. Geneva. Available from:www.who.int/healthsystems/GHIsynergies/en/index.html
3.
Freedman LP, Waldman RJ, de Pinho H, Wirth ME, Chowdhury AMR, Rosenfield A. 2005.
Who's got the power? Transforming health systems for women and children. UN Millennium
Project Task Force on Child Health and Maternal Health 2005. Geneva: UNDP.
4.
World Bank. 2007. What is a health system? The World Bank Strategy for HNP Results.
Available from: www.worldbank.org/
5.
WHO REGIONAL COMMITTEE FOR AFRICA Fifty-third session Johannesburg, South Africa, 1–5
September 2003 http://afrolib.afro.who.int/RC/RC53/en/AFR.RC53.R2.pdf
6.
Rais Akhtar; Health Care Patterns and Planning in Developing Countries, Greenwood Press,
1991. pp 264
7.
The World Health Organization Country Office Annual Report www.who.int/countries/nga
8.
2nd International Conference On Health Promoting Hospitals held in Padova Italy
http://www.hph-hc.cc/Downloads/Conferences/proceedings-1994.pdf
9.
Lagos State of Nigeria Official Gazette No 36, Vol 39 Notice no 73 A Law to provide for the
Reform of the Lagos State Health Sector, Lagos State Hospitals Management Board, Primary
Health Care Board, Traditional Medicine Board and for connected purposes 28th August
2006
Hospital Management Committees were also established. They
are to manage the affairs of the hospitals on a day-to-day basis.
This committee consists of all the heads of departments, clinical
and non clinical in the hospital.
The functions of the Health Management Committee is to assist
the Chief Medical Director in the day-to-day management of the
hospital and to ensure proper medical care of patients in the
hospital; and to implement executive decisions of the Governing
Board with regard to the overall planning, expansion, development
and maintenance of the hospital or health institutions within its
jurisdiction; the revenues and expenditures of the hospital and the
purchase of stores, furniture and equipment within the limits
approved by the Governing Board.
On their own part the Medical Directors will essentially handle
the day to day management of human, financial and material
resources of the hospital(s) in accordance with the objectives and
targets set by the Governing Board of Hospital(s).
Considering the fact that there is a lot of clandestine and
substandard medical practice in the private sector in Lagos state,
the HSR also established the Health Facility Monitoring and
Accreditation Agency which serves to ensure that all health
38 World Hospitals and Health Services Vol. 47 No. 3

The evolving role of hospitals in health systems: Lesotho
The Lesotho Hospital PPP
experience: catalyst for
integrated service delivery
CARLA FAUSTINO COELHO
INVESTMENT OFFICER, INTERNATIONAL FINANCE CORPORATION
(IFC)
CATHERINE COMMANDER O’FARRELL
SENIOR INVESTMENT OFFICER, INTERNATIONAL FINANCE
CORPORATION (IFC)
ABSTRACT: For many years, Lesotho urgently needed to replace its main public hospital, Queen Elizabeth II. The project
was initially conceived as a single replacement hospital, but eventually included the design and construction of a new
425 bed public hospital and adjacent primary care clinic, the renovation and expansion of three strategically located
primary care clinics in the region and the management of all facilities, equipment and delivery of all clinical services in
the health network by a private operator under contract for 18 years. The project’s design was influenced by the
recognition that a new facility alone would not address the underlying issues in service provision. The creation of this
PPP health network and the contracting mechanism has increased accountability for service quality, shifted Government
to a more strategic role and may also benefit other public facilities and providers in Lesotho. The country is considering
the PPP approach for other health facilities.
Many governments have poorly functioning facilities and
want to replace them but will this solve the problem?
Unless the underlying causes are addressed, a new
facility can become an expensive new home for many of the same
problems. Lesotho is a small mountainous country in southern
Africa with a population of 2 million where government has
adopted a new model for the integrated management and delivery
of health services. The project arose from circumstances that are
familiar to many governments – failing health infrastructure, poor
quality services, and resource constraints. What makes this
project different is Government’s response to these
circumstances, which was an examination of the underlying
problems and an open approach to tailoring solutions.
The Lesotho government had struggled to improve services at
the existing Queen Elizabeth II hospital for years. In less than five
years, the hospital’s budget had almost tripled, yet the level and
quality of care had actually declined. With many services
unavailable, patients would cross the border to access South
African hospitals, ultimately creating more bills for government and
crowding out local patients in South Africa. Lesotho has fiscal
constraints and an increasing health and economic burden of
HIV/AIDS and related conditions, so Government decided that this
ineffective spending in such a critical sector was unsustainable.
In 2006, Lesotho requested assistance from the International
Finance Corporation (IFC, part of the World Bank Group) to
explore options for including the private sector in a new hospital
project for the capital city of Maseru. The IFC team included PPP
experts together with clinical and other technical specialists who
assisted Government in designing and implementing this project.
The initial concept was for a single replacement hospital, yet the
final project was much broader, including the design, construction,
and equipping of the new 425 bed public hospital and adjacent
primary care clinic, refurbishment, expansion and upgrade of three
regional primary care clinics, all facility and equipment
management and all clinical services, creating a health network
operated by the private partner. The new hospital functions as the
nation’s referral hospital, serves as a district hospital for greater
Maseru, and is the nation’s major clinical teaching site for
physicians, nurses, and other allied health professionals. The
competitive tender resulted in the selection of Tsepong, a
consortium led by Netcare, a leading South African and U.K.
health provider, together with a women-owned investment group
and local and expatriate health care professionals.
There were many considerations for sustainable project design.
Could the country afford new facilities and better public care?
What was the appropriate mix of services, quantity, and quality of
care that would be affordable? What indicators should be used for
evaluating the performance of the new management, staff and
facilities? To answer these questions, a detailed survey was
constructed to examine the health care costs and services at
Queen II and the existing primary care clinics.
The Baseline Survey
A team of doctors, nurses, health administrators, and statisticians
from the Lesotho-Boston Health Alliance (LeBoHa) spent more
than six months assessing the physical facilities, quality of medical
World Hospitals and Health Services Vol. 47 No. 3 39

The evolving role of hospitals in health systems: Lesotho
records and patient management, referrals to South Africa’s
hospitals, interviewing patients, observing hospital and filter
clinics' technical capacity, and surveying personnel about existing
practices, service delivery and staff morale. This baseline study
included four different surveys conducted between June 2007 and
June 2008.
The results revealed that the situation was far worse than
anyone had expected. Queen II had neither emergency nor lifesaving
equipment readily available in most departments. The
hospital was not meeting the fundamentals for patient care of for
the majority of very sick patients due to the lack of standard
diagnostic testing, intravenous therapy and other causes, despite
the availability of equipment and supplies.
The burden of illness revealed by the baseline study would
challenge any government and any hospital and was especially
daunting in the context of the staffing, equipment, and
management challenges at the existing hospital. Infection control,
whether for TB or other infections, was a serious problem.
Malnourished children accounted for 25% of all pediatric medical
admissions, with pneumonia in children even more common.
The study found many physicians and nurses in Queen II to be
well-intentioned, compassionate, and, in the case of several
specialists, extraordinarily skilled by any standard. Yet, the low
quality of services in the hospital was partially the product of
management failures and lack of accountability. The hospital, for
example, used an outmoded, error-prone, “team” approach to
patient care with jobs are divided among nurses for specific types
of care so that no single nurse was accountable for a particular
patient or for keeping track of a patient’s overall condition and
changing needs. Doctors and nurses rarely washed their hands;
there were 54 hand-washing stations in the wards, of which, 52
had running cold water, but none had soap.
Primary care clinics were similarly understaffed and poorly
equipped. Patients often bypassed the clinics entirely and either
went directly to Queen II, overwhelming the hospital with
patients, or crossed the border into South Africa in an attempt to
access services.
All these findings confirmed one of the key arguments for using
a new approach to improving the health care in Lesotho. Without
drastic changes in management including the introduction of
adequate supervision, mentoring, training, reorganization of job
profiles and content and accountability for personal performance
linked to meaningful incentives, new buildings and equipment
would not be enough to make meaningful changes in the health
system. New facilities must be accompanied by systematic
changes in how health professionals work.
In the interim: quick fixes
The baseline study identified nearly a dozen low cost changes that
could be instituted immediately to significantly upgrade care at the
existing hospital while construction was underway. Suggested
changes included regular stocking of soap at all hand washing
stations, overhauling laundry services, a new management system
for nurses to make a single nurse accountable for several patients,
and improvements to chart maintenance, particularly medication
records. Simple but effective improvements were also identified in
the triage system for casualty admissions and in the collection and
analysis of bacteriology samples. These suggestions yielded some
good interim results from rapid corrective actions by the Ministry
of Health.
The clinics were rapidly expanded and upgraded and opened
while the new hospital was under construction. This reduced
pressure on the existing old hospital and began to change patient
behavior by building trust in locally available services.
What makes this project different?
Health sector PPPs typically range from simple outsourcing of
support services (such as catering or laundry) to the more
complex design, build, and facilities management of hospitals. The
Lesotho PPP structure is a first for Africa—and one of only a
handful of similar projects worldwide. In addition to the design,
construction and full operation of all facilities, the private operator
has full responsibility for delivery of all clinical services, including
recruitment of doctors, nurses, and other health professionals,
and provision of all medical equipment and all pharmaceuticals
necessary for clinical services delivery.
The baseline study revealed that volume pressures on the
existing hospital came from service gaps at the primary care level.
The project’s health network design covers the greater Maseru
area and this structure allows for treatment of less severe cases
at the clinic level, freeing up hospital capacity and working to
contain costs.
Government as strategic purchaser
The Government of Lesotho has effectively become an active,
strategic purchaser of health services using a contract that defines
the type and number of services, the annual payment for the
services as well as the payment mechanism and performance
indicators.
This contract, monitored independently, provides Government
with a measure of certainty and accountability in terms of budget,
service quality, facility and equipment maintenance and other
provider obligations. The contract also provides mechanisms for
service penalties, dispute resolution and the flexibility to address
future needs.
Payment and performance monitoring
The private operator delivers a defined service package, agreeing
to treat all patients presenting at the hospital and filter clinics, up
to a maximum of 20,000 inpatients and 310,000 outpatients per
annum—with very few clinical exceptions. The government
provides the private operator with an annual fixed service
payment, escalated only by annual inflation. Private operators in
similar PPPs, reluctant to commit to a fixed cost for clinical care,
have historically opted for direct-cost-plus-margin payments until
patient profiles and disease patterns could be established. In this
case, the baseline study provided that information.
The agreement includes typical payment and penalty
mechanisms related to facilities management, equipment, and
other nonclinical service outcomes. Detailed clinical and nonclinical
service indicators must be met in order to receive full
payment from the government. Failure to do so results a deduction
of a percentage of the total service payment, with the relative
importance of clinical versus facilities performance indicators is
reflected in the percentages deducted. Repeated failures can
eventually result in termination. The facilities must also obtain and
40 World Hospitals and Health Services Vol. 47 No. 3

The evolving role of hospitals in health systems: Lesotho
maintain accreditation from the Council for Health Services
Accreditation of Southern Africa.
The project has an independent monitor specifically created for
this project to perform quarterly audits against the contractual
performance indicators (clinical and nonclinical) and, where
performance has not been achieved, determine the penalty
deduction that applies. The independent monitor is a consortium
of companies with specialized experience in PPPs, clinical
services, hospital operation and management, medical and
nonmedical equipment, information management and technology,
and soft and hard facilities management.
For the flexibility required in a long term project, there is a Joint
Services Committee, established by the government and the
private operator, to review performance and discuss and develop
improvements and to address changes in disease patterns, new
technologies, or new national priorities, thereby ensuring that the
project remains relevant for the country.
Outcomes
The PPP agreement for this project was signed by the government
and the private operator on October 2008. The expanded and
refurbished primary care clinics were opened in May 2010 and the
new hospital had its official opening in October 2011.
Although the project is still in its early stages and the expectation
of success is high, there will certainly be challenges and obstacles
for the private operator and the government. There is a high
probability that the hospital will reach maximum capacity very early
in the project term, requiring the government to rapidly improve
the service offering at other health facilities to relieve the pressure
on the new public hospital.
Government is working with the Millennium Challenge
Corporation to fund refurbishment of over 150 health facilities
across the country, including 138 primary health care centres. The
project is underway, with construction started and the
refurbishment and expansion of all facilities expected by 2013.
Once completed, the government will become responsible for
ongoing facilities management. Given the experience thus far,
government is considering a new PPP project that would provide
these additional health facilities with ongoing facilities
management, ICT and equipment maintenance services in order
to ensure the long-term sustainability of the refurbishment
program and continuity of services.❏
Carla Faustino Coelho is an Investment Officer at the International
Finance Corporation, advising Governments in the identification
and structuring of Public Private Partnerships for health, water and
sustainable energy in the Southern Africa region. She holds an
M.B.A. from the University of the Witwatersrand. Carla worked
extensively on the Lesotho Hospital PPP project and continues to
work with the Government on PPPs in health and other sectors.
Catherine Commander O’Farrell is a Senior Investment Officer at the
International Finance Corporation, advising Governments in the
identification and structuring of Public Private Partnerships for health
and other public services, primarily in Africa and in other regions.
She has an M.B.A. from the George Washington University.
Catherine led the Lesotho Hospital PPP project and is working on a
similar project in West Africa, as well as other health PPPs in Africa.
World Hospitals and Health Services Vol. 47 No. 3 41

Reference
World Hospitals and Health Services 2011 Volume 47 Number 3
Résumés en Français
ROLE DES HOPITAUX DANS LE CADRE DE LA NOUVELLE
STRATEGIE DE SOINS DE SANTE PRIMAIRE (SSP)
Résumé : Cet article résume un exposé présenté au Sommet de
leadership de la FIH qui a eu lieu à Chicago aux Etats-Unis en juin
2010 par Denis Porignon de l’Organisation mondiale de la santé
(OMS) et Reynaldo Holder de l’Organisation pan-américaine de la
santé (PAHO/OMS). Il examine le rôle des hôpitaux dans le cadre
de la nouvelle stratégie de SSP.
RÔLE DES HÔPITAUX DANS LE PAYSAGE CHANGEANT DES
SOINS DE SANTÉ DANS LES EMIRATS: COUP D’ŒIL SUR DUBAÏ
Résumé: Dans les Emirats Arabes Unis, les services de santé ont
connu un grand essor en quarante ans, et la santé de la
population connait une amélioration spectaculaire. Le secteur
hospitalier est en forte croissance, avec des investissements du
secteur privé. Cependant, les besoins présents et futurs de la
population sont complexes et peuvent n’être pas adéquatement
satisfaits par l’expansion constante de la capacité hospitalière.
Dans cet article qui utilise l’Emirat de Dubaï comme cas-type,
nous examinons les changements qui sont intervenus dans les
services de santé et tentons de prédire leur configuration et leur
capacité optimales dans l’avenir, compte tenu des structures et de
la croissance, de la morbidité et de l’utilisation des services.
LES HÔPITAUX DE L’AVENIR
Résumé : Les hôpitaux et les services de santé sont confrontés à
une demande de changements sans précédent à court et à long
terme, allant de changements démographiques à une
dépendance croissante en paiement fondé sur la valeur et aux
incertitudes pesant sur la réforme gouvernementale. Le comité
Amélioration des performances du Conseil d’administration de
l’Association hospitalière américaine (AHA) a lancé un projet
d’identification des dix stratégies les plus efficaces que tous les
hôpitaux doivent adopter pour devenir les systèmes de santé
performants de l’avenir. Cette enquête du comité a permis de
mettre en lumière quatre stratégies primordiales : 1) Aligner les
hôpitaux, les médecins et tous les prestataires sur tout le
continuum de soins; 2) Faire appel aux pratiques basées sur les
preuves pour améliorer la qualité et la sécurité des patients; 3)
Améliorer l’efficacité par la productivité et la gestion financière, et
4) Elaborer des systèmes d’information intégrés. Cet article définit
dix stratégies et les mesures requises pour les mettre en œuvre.
LES THÉORIES QUI SOUS-TENDENT LES RÉFORMES DE SANTÉ
AUX ETATS-UNIS – IMPLICATIONS STRATÉGIQUES POUR LES
HÔPITAUX
Résumé : La réforme du système de santé américain (ACA,
Affordable Care Act, Loi sur les soins abordables) présente aux
prestataires de santé les objectifs qu’il faut accomplir dans le
cadre de la réforme des soins et les motifs de ces objectifs. Toute
organisation de santé désireuse d’élaborer des stratégies visant à
la mise en œuvre des politiques de cette loi doit prendre en
compte ses théories sous-jacentes, à savoir:
• Gestion du changement par la conception des paiements et les
flux de fonds
• Concurrence sur le marché
Pour exécuter cette stratégie, il est essentiel de gérer
efficacement l’administration interne, qui sera facilitée par un
alignement solide entre la mission et les facteurs opérationnels. La
mission doit être coordonnée aux marchés de l’organisation. Il faut
aborder les marchés en fonction d’une perspective locale par
laquelle les objectifs ACA peuvent se définir au sein d’une
communauté ou d’une culture spécifique. L’approche par
systèmes implique autant de participants au système pour définir
leur succès mutuel par rapport à la réforme.
EFFETS DES MODES DE PAIEMENT SUR LE COMPORTEMENT
HOSPITALIER AU BRÉSIL: OBSERVATIONS D’UN SYSTÈME DE
PAYEURS MULTIPLES ET D’UN SYSTÈME DE PAIEMENTS
MULTIPLES
Résumé : On utilise au Brésil un certain nombre de systèmes de
rémunération des prestataires (SRP) pour orienter les fonds vers
les hôpitaux. Cet article examine leurs répercussions sur
l’efficacité, les coûts et la qualité des hôpitaux. Les hôpitaux
publiques financés par un budget public traditionnel par postes
sont les moins efficaces. Ceux financés par des budgets globaux
et par d’autres systèmes de budgets décentralisés fonctionnent
aussi efficacement que les prestataires privés financés par des
plans de santé privés pré-payés. Les cliniques privées qui
dépendent de rémunérations gouvernementales présentent des
niveaux de qualité inférieurs. Toutefois, les effets globaux des SRP
sur les performances sont moins importants que prévu pour
certains groupes d’hôpitaux. L’article étudie les facteurs qui
compromettent l’impact des SRP sur les performances.
HÔPITAUX ET SYSTÈMES DE PRESTATIONS : LE BESOIN DE
CHANGEMENT
Résumé: Les hôpitaux de toute l’Europe sont confrontés à
d’énormes contraintes et nécessitent de profonds changements.
Ils sont mal outillés pour faire face à ces défis et dans bien des cas,
les cadres de politiques ne sont guère adaptés pour leur faciliter
le changement. Les hôpitaux ont de plus en plus besoin d’être
considérés dans un cadre plus large, et des solutions novatrices
s’imposent pour résoudre les problèmes qu’ils affrontent.
MIEUX QUE LE MARC DE CAFÉ ! LA SIMULATION PERMETTRAIT
DE PRÉDIRE LES FUTURS PROBLÈMES DU SYSTÈME DE SANTÉ
AUSTRALIEN
Résumé: En 2007, le changement de gouvernement national en
Australie a donné lieu à une démarche de révision et de réforme
42 World Hospitals and Health Services Vol. 47 No. 3

Reference
du système de santé qui est actuellement mis en oeuvre.
L’Association australienne de la santé publique et des hôpitaux
(AHHA) a mené un exercice de simulation pour créer un modèle
des répercussions probables des réformes planifiées.
Cet article décrit le cadre général de ces changements, le
processus de consultation et de mise en œuvre des réformes, et
les résultats de l’exercice de simulation. Cette démarche a permis
de déterminer les risques inhérents à la réforme et le besoin de
résoudre les problèmes structurels à long terme dans le système
de santé australien en vue d’assurer des soins optimaux centrés
sur le patient.
REDISTRIBUTION DES JEUX SUR LE MARCHÉ HOSPITALIER
SUISSE
Les hôpitaux suisses sont confrontés à deux bouleversements
majeurs : d’une part, l’introduction de groupes par diagnostic pour
fixer les paiements et de l’autre, la pénurie de personnel découlant
des changements démographiques. Ils résoudront les difficultés
en renforçant leurs systèmes comptables pour pouvoir calculer les
coûts par patient. De premières mesures visant à attirer des
nouveaux personnels hospitaliers sont prises au sein du nouveau
système de formation professionnelle. Un troisième changement
est difficile à prédire : le paysage fluctuant des compagnies
d’assurances médicales sociales.
ROLE EVOLUTIF DES HOPITAUX DANS LES SYSTEMES DE
SANTE: LAGOS AU NIGERIA
Résumé: Face à la révision des définitions des systèmes de santé
et aux attentes du public, il est nécessaire de réévaluer le rôle des
hôpitaux. Les hôpitaux restent au centre des services de santé, et
doivent relever de nombreux défis en matière de prestations de
services. L’Etat de Lagos au Nigéria a analysé son cas particulier
et préparé une Loi de réforme des services de santé. Cette loi
veut restructurer le système étatique de santé, notamment sous
l’angle du fonctionnement des hôpitaux. Cet article souligne le
rôle des hôpitaux en général en analysant comment la réforme
des services de santé tente d’améliorer les hôpitaux de Lagos et
le système de santé.
L’EXPÉRIENCE DU PPP À L’HÔPITAL DU LESOTHO:
CATALYSEUR DES PRESTATIONS DE SERVICES INTÉGRÉS
Résumé : Depuis de longues années, il est urgent que le Lesotho
remplace son principal hôpital public, le Queen Elizabeth II.
Initialement conçu pour le remplacement d’un seul hôpital, le
projet a fini par inclure la conception et la construction d’un nouvel
hôpital public de 425 lits et la Clinique Gateway adjacente, la
rénovation et l’expansion de trios cliniques stratégiques dans la
région et la gestion de tous les locaux et équipements et la
prestation de tous les services cliniques dans le réseau de santé
par un opérateur privé sous contrat depuis 18 ans. La conception
du projet était influencée par la prise de conscience du fait qu’un
seul établissement nouveau ne pouvait pas résoudre tous les
profonds problèmes de prestation de services. La création de ce
réseau de santé PPP et le mécanisme contractuel a haussé le
niveau de responsabilité pour la qualité de service, motive le
gouvernement à jouer un rôle plus stratégique et pourrait
également être bénéfique aux autres établissements publics et
prestataires du Lesotho. Le pays envisage d’appliquer l’approche
PPP à d’autres établissements de santé.
World Hospitals and Health Services 2011 Volume 47 Number 3
Resumen en Espanol
EL PAPEL DE LOS HOSPITALES DENTRO DEL MARCO DE LA
ESTRATEGIA PARA UNA ATENCION PRIMARIA DE SALUD (EN
INGLES PHC) RENOVADA
Este artículo es un resumen de una disertación hecha
conjuntamente por Denis Porignon de la Organización Mundial de
la Salud (OMS) y Reynaldo Holder de la Organización
Panamericana de la Salud (en inglés PAHO/WHO), durante una
Conferencia de alto nivel de la FIH, celebrada en Chicago, EE UU,
en junio de 2010. La ponencia trata del papel de los hospitales
dentro del marco de la estrategia para una atención primaria de
salud renovada.
EL PAPEL DE LOS HOSPITALES EN EL ENTORNO EN PROCESO
DE CAMBIO DE LA ATENCIÓN DE LA SALUD DE LOS EMIRATOS
ARABES UNIDOS: ENFOQUE HACIA DUBAI
El servicio de la salud ha evolucionado en gran manera en los
Emiratos Arabes Unidos en los últimos cuarenta años, con lo cual
la salud de la población ha experimentado una mejora muy
notable. El sector hospitalario está creciendo de manera muy
significativa gracias a la inversión del sector privado. No obstante,
las necesidades actuales y futuras de la población en materia de
salud son muy complejas y es posible que la ampliación sostenida
de la capacidad hospitalaria no sea suficiente para cubrir esas
necesidades. En este informe, haciendo uso del Emirato de Dubai
para un estudio de casos, se examinan los cambios que han
experimentado los servicios de salud y se intenta predecir la
configuración y capacidad óptimas en el futuro, teniendo en
cuenta la estructura y el crecimiento demográficos, así como los
niveles de morbilidad y la utilización de los servicios.
LOS HOSPITALES DEL FUTURO
Los hospitales y sistemas de salud del mundo se enfrentan hoy en
día a una demanda de cambio sin precedentes, tanto a corto
World Hospitals and Health Services Vol. 47 No. 3 43

Reference
como a largo plazo, que va desde un cambio demográfico a una
dependencia cada vez mayor de los pagos basados en el precio,
así como a la inseguridad que implica una reforma gubernamental.
El Comité de la Junta sobre la mejora del nivel de rendimiento de
la Asociación Americana de Hospitales emprendió una iniciativa
encaminada a identificar las diez estrategias principales que
deberían poner en marcha todos los hospitales con el fin de
convertirse en sistemas de atención de la salud del futuro con
buenos resultados. Como consecuencia de la encuesta del
comité, se identificaron las cuatro estrategias principales
siguientes: 1) La armonización de los hospitales, los médicos y
demás proveedores de asistencia sanitaria de una parte a otra de
la esfera de los cuidados de salud; 2) El uso de prácticas basadas
en los hechos con miras a mejorar la calidad de los cuidados y la
seguridad de los pacientes; 3) Mejorar la eficiencia mediante la
productividad y la gestión financiera; y 4) Instalando sistemas de
información integrados. Este artículo ofrece un resumen de diez
estrategias y las correspondientes medidas encaminadas a
evaluar el logro de esos objetivos.
TEORIAS FUNDAMENTALES DE LAS REFORMAS SANITARIAS
EN LOS ESTADOS UNIDOS: REPERCUSIONES DE ESTA
ESTRATEGIA PARA LOS HOSPITALES
Las reformas sanitarias de los Estados Unidos (Decreto de Ley
sobre la asistencia con capacidad de pago, en inglés Affordable
Care Act (ACA) presenta a los proveedores de asistencia sanitaria
los objetivos que se deberían alcanzar en el marco del servicio de
salud tras la puesta en práctica de esas reformas, así como la
lógica de los objetivos en cuestión. Las estrategias en vías de
desarrollo encaminadas a poner en marcha las políticas del
decreto por parte de cualquier organización sanitaria habrán de
tener en cuenta las siguientes teorías fundamentales del Decreto
de Ley:
• Reforma controlada mediante una estructura de pago y
utilización de fondos
• Competencia del mercado
Con el fin de llevar a cabo esta estrategia es imperativo que haya
una gestión orgánica interna eficaz, algo que se puede lograr
gracias a una sólida armonización entre los objetivos y los factores
de gestión. Los objetivos deberán estar relacionados con el
mercado de la organización, mientras que la mejor manera de
dirigirse al mercado consiste en enfocarlo desde una perspectiva
local por la que los objetivos de la Ley sobre la asistencia con
capacidad de pago se puedan poner en práctica en una
comunidad o cultura específica. El enfoque por sistemas reúne a
tantos participantes con el fin de definir el éxito de cada uno de
ellos en lo que respecta a las reformas.
CONSECUENCIAS DE LOS DISTINTOS MECANISMOS DE PAGO
SOBRE LA ACTUACION DE LOS HOSPITALES EN BRASIL:
PRUEBAS DE UN SISTEMA DE PAGOS Y FINANCIACION
MULTIPLES
Brasil cuenta con toda una variedad de mecanismos de pago
(PPMS) de los proveedores de asistencia sanitaria para destinar
fondos a los hospitales. Este artículo estudia las consecuencias
sobre la eficiencia, los costes y la calidad en los hospitales. Los
hospitales públicos financiados mediante los presupuestos
públicos tradicionales de partidas presupuestarias son los que
tienen peor rendimiento, mientras que aquéllos financiados a
través de presupuestos globales y otras modalidades
presupuestarias descentralizadas funcionan a la par con los
proveedores privados financiados principalmente por seguros de
enfermedad privados. Los hospitales privados que dependen de
la financiación del Estado tienen un nivel inferior de calidad. No
obstante, las consecuencias totales de los PPMS sobre el
rendimiento son inferiores de lo que se esperaba para algunos de
los hospitales. Este informe examina los factores implicados en las
consecuencias de los PPMS sobre el rendimiento hospitalario.
LOS HOSPITALES Y LOS SISTEMAS DE PRESTACIÓN DE LOS
SERVICIOS DE SALUD: LA NECESIDAD DE UN CAMBIO
Todos los hospitales de Europa trabajan bajo una gran presión y
necesitan una cambio. Estos no están realmente en condiciones
para hacer frente a semejante reto y en muchos de los casos ni
siquiera su estructura normativa cuenta con los medios para
ayudarles a efectuar esa reforma. Cada vez hay mayor necesidad
de que los hospitales se consideren parte integrante de todo el
sistema de salud y por tanto necesitan unas soluciones enérgicas
y muy imaginativas con el fin de hacer frente a los problemas con
los que se enfrentan.
¿MEJOR QUE UNA BOLA DE CRISTAL? EL USO DE LA
SIMULACION PARA PREVER LOS PROBLEMAS POTENCIALES
DEL SISTEMA DE SALUD DE AUSTRALIA
Un cambio del gobierno de Australia en el 2007 ha dado lugar a
un proceso de análisis y reformas del sistema de salud que se
está poniendo en práctica en la actualidad. La Asociación
Australiana de asistencia sanitaria y hospitales (AHHA en inglés)
puso en práctica un ejercicio de simulación encaminado a estudiar
las posibles repercusiones de las reformas proyectadas.
Este artículo describe el trasfondo de dichas reformas, el
proceso de asesoramiento y puesta en marcha de las reformas,
así como los resultados del ejercicio de simulación. El proceso
señala los peligros propios de las reformas y la necesidad de
abordar los problemas estructurales a largo plazo del sistema de
salud de Australia con el fin de velar por unos cuidados de salud
óptimos centrados en el paciente.
REORGANIZACIÓN DEL CONJUNTO DE HOSPITALES EN EL
MERCADO HOSPITALARIO SUIZO
Los hospitales suizos se enfrentan con dos reformas de
envergadura: la primera es la introducción de los GDR (Grupos de
diagnósticos relacionados) como moneda de pago y la segunda
es la escasez de personal debido a los cambios demográficos.
Esto deberán hacerlo reforzando sus sistemas de contabilidad
con el fin de poder calcular el coste por paciente. Se toman las
primeras medidas encaminadas a atraer personal nuevo dentro
del marco del nuevo sistema de enseñanza profesional. La tercera
reforma, el panorama en evolución de las compañías de la
seguridad social es difícil de pronosticar.
LA EVOLUCION DEL PAPEL QUE DESEMPEÑAN LOS
HOSPITALES EN EL SENO DEL SISTEMA DE SALUD: EL ESTADO
DE LAGOS, NIGERIA
Con la modificación de la definición de los sistemas de salud y las
expectativas del público hay una verdadera necesidad de llevar a
cabo una reevaluación del papel que desempeñan los hospitales.
44 World Hospitals and Health Services Vol. 47 No. 3

Reference
Estos siguen siendo el centro de los servicios de salud y hacen
frente a toda una serie de retos en la prestación de la salud. El
Estado de Lagos en Nigeria ha realizado un análisis de sus
circunstancias tan características tras el cual ha formulado una ley
para reformar el servicio de salud de su estado. Dicha ley pretende
llevar a cabo una reestructuración del sistema de salud del Estado
de Lagos, poniendo énfasis en particular en la mejora del
funcionamiento de los hospitales. Este artículo pone de relieve el
papel de los hospitales en general y lleva a cabo un estudio más
a fondo sobre la manera en la que las reformas del Servicio de
salud se proponen mejorar los hospitales y el sistema de salud de
Lagos.
EL PROYECTO DEL HOSPITAL LESOTHO DENOMINADO PPP:
EFECTO CATALIZADOR PARA LA PRESTACIÓN INTEGRAL DEL
SERVICIO DE SALUD
Durante años, Lesotho tuvo la necesidad urgente de sustituir su
principal hospital público, el Queen Elizabeth II. Si bien en un
principio se proyectó construir otro hospital para sustituir al
antiguo, el proyecto definitivo comprendió la construcción de un
nuevo hospital público con capacidad para 425 camas y una
clínica adyacente de atención primaria de salud, la renovación y
ampliación de tres clínicas de atención primaria de salud, situadas
en la región de manera estratégica, y la gestión de todas las
instalaciones, el material y equipamiento y la prestación de todos
los servicios clínicos del sistema de salud a cargo de un
organismo privado contratado por un plazo de 18 años. El
proyecto se diseñó por reconocer que las nuevas instalaciones
por sí solas no serían suficientes para solucionar los problemas
subyacentes relativos a la prestación de los servicios. La creación
de este sistema de salud denominado PPP y el mecanismo de
contratación han mejorado la capacidad de respuesta de la
calidad de los servicios, obligado al gobierno a desempeñar un
papel más estratégico y hasta es posible que sirvan para
beneficiar a otros establecimientos públicos y proveedores de
asistencia sanitaria de Lesotho. Tal es así, que este país está
pensando poner en marcha el proyecto PPP en otros servicios de
salud.
World Hospitals and Health Services Vol. 47 No. 3 45

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HIMSS Analytics helps you achieve new heights with invaluable resources, exclusive opportunities and a global network:
LAS VEGAS, NEVADA
20-24 FEBRUARY 2012
COPENHAGEN, DENMARK
7-9 MAY 2012
ABU DHABI
21-23 MAY 2012
SINGAPORE
17-19 SEPTEMBER 2012
To learn more about our data collection efforts per region and how
to obtain your EMRAM score, visit one of the following websites:
ASIA www.himssanalyticsasia.org
EUROPE www.himssanalytics.eu
US www.himssanalytics.org

IHF corporate partners
Meet IHF corporate partners
is a global leader in professional services, providing award-winning food services, management of facilities, assets, and clinical
technology, and uniform/career apparel to health care institutions and other businesses. In FORTUNE magazine's 2010 list of "World's
Most Admired Companies," ARAMARK ranks number one in its industry, consistently ranking since 1998 as one of the top three most
admired companies in its industry. ARAMARK seeks to responsibly address key issues by focusing on employee advocacy, environmental
stewardship, health and wellness, and community involvement. Headquartered in Philadelphia, Pennsylvania (USA), ARAMARK’s 255,000
employees serve clients in 22 countries.
Visit www.aramark.com
is the centre of a community comprised of over 15,000 players of the hospital business. Through our web platform, we integrate hospitals
throughout the supply chain sector, focusing on business development and relationships. Established in 2000, in just 10 years, Bionexo
was structured in Brazil, becoming the largest marketplace reference to the hospital industry and contributing significantly to the
professionalization of the purchasing sector and growth of the healthcare market.
The success of this innovative business model has led to Bionexo for Latin America and Europe, where also attained leadership in addition
to export technology and implement a new concept in commercial transactions of organizations. Everything happened in a short time, just
like businesses are made between the companies that integrate our platforms. This makes Bionexo the largest core of the hospital sector
in Brazil. Pioneering and innovation, helping thousands of companies and hospitals.
www.bionexo.com.br
is the world leader in GIS technology. On any given day, more than one million people around the world use Esri geographic information
system (GIS) software to improve the way their organizations conduct business. Esri GIS solutions are becoming an integral component of
health organizations in addition to nearly every other type of business and government service. By adding a geographic component to
data and analysis, Esri software promotes exploring, analyzing and visualizing massive amounts of information according to spatial
relationships. Since most health and human service problems facing the world today exist in a location-based context, geography can
play a major role in helping health professionals understand health dynamics and the spread of disease. Health surveillance systems are
used to gather, integrate and analyze health data; interpret disease transmission and spread; and monitor the capabilities of health
systems. GIS is the enabling technology to spatially relate much of the information, making it a powerful tool for identifying, tracking and
responding to disease patterns and health service needs. Esri software is extensively used by health organizations throughout the world,
including the US Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), 119 national health ministries,
and over 500 hospitals. For more information, contact Ann Bossard, abossard@esri.com. www.esri.com/health
World Hospitals and Health Services Vol. 47 No. 3 47

IHF corporate partners
owns the Capital’s six leading private hospitals all based in central London and each with an international reputation for the highest
standards of care. They are: The Wellington – the largest private hospital in Europe, The London Bridge Hospital, The Harley Street Clinic,
The Portland Hospital for Women and Children, The Lister Hospital and The Princess Grace Hospital. HCA also has four outpatient and
diagnostic centres – soon to be six – a blood and bone cancer treatment joint venture with the NHS at University College Hospital, The
London Gamma Knife Centre, another joint venture with the NHS at St Bartholomew’s Hospital and Harley Street at Queen’s, a private
patient cancer centre at the NHS Queen’s Hospital in Romford.
The six HCA hospitals treat around 300,000 patients per year. They also specialise in the most complex medical procedures including
cardiac care, liver transplantation, inter cranial surgery and complex cancer care. The HCA CancerCare network, for example, is the largest
provider of cancer care in the UK outside the NHS. Uniquely, HCA has its own clinical trials unit based in Harley Street in central London.
Medical teams in HCA are involved in research programmes aimed at finding new treatments in areas such as heart disease and cancer. In
recent years HCA has invested around £250 million in capital expenditure including new diagnostic and treatment technology. As an
example, HCA has recently installed at The Harley Street Clinic, the revolutionary CyberKnife robotic radiotherapy machine, which is able
to target previously untreatable tumours. It is the first machine of its kind in the UK.
www.hcainternational.com
a business of Ingersoll Rand – the world leader in creating and sustaining safe, comfortable and energy efficient environments – creates
ideal environments of care for healthcare organizations all over the globe. Our products, services and solutions optimize the link between
the physical environment to patient outcomes, staff satisfaction/productivity and the bottom line.
Trane/Ingersoll Rand solutions optimize healing environments with a broad portfolio of energy efficient heating, ventilating and air
conditioning systems, building and contracting services, parts support and advanced controls for healthcare buildings. Our market-leading
products also include electronic and biometric access control systems; time and attendance and personnel scheduling systems;
mechanical locks and portable security, door closers and exit devices, steel doors and frames, architectural hardware and technologies
and services for global healthcare markets.
www.Trane.com and www.ingersollrand.com
uses its 125 years of experience to help healthcare organizations create comfortable, safe and sustainable healing environments while
providing measurable results. By utilizing our expertise in energy and sustainability, facilities, building and technology infrastructure,
healthcare organizations can improve their financial results, the environment of care and their standing in the community. Johnson
Controls provides design assist and construction management, funding solutions, network integration solutions for clinical and nonclinical
systems, energy management and central utility plants, operations support and best practices, systems maintenance and facility
management services. Johnson Controls helps healthcare organizations create comfortable, safe and sustainable healing environments
while providing measurable results.
www.johnsoncontrols.com
MEDTRONIC is the global leader in medical technology- alleviating pain, restoring health, and extending life for people with chronic
conditions around the world. Medtronic develops and manufactures a wide range of products and therapies with emphasis on providing a
complete continuum of care to diagnose, prevent and monitor chronic conditions. Each year, Medtronic therapies help more than seven
million people.
Founded: April 29, 1949 in Minneapolis, Minnesota, USA, by Earl E. Bakken and Palmer J. Hermundslie.
Financial: Revenue for the year ended April 24, 2009: $14.6 billion. New York Stock Exchange ticker: MDT.
For further information please visit www.medtronic.com
48 World Hospitals and Health Services Vol. 47 No. 3

IHF corporate partners
ROYAL PHILIPS ELECTRONICS OF THE NETHERLANDS (NYSE: PHG, AEX: PHI) is a diversified health and well-being company, focused on
improving people’s lives through timely innovations. As a world leader in healthcare, lifestyle and lighting, Philips integrates technologies
and design into people-centric solutions, based on fundamental customer insights and the brand promise of “sense and simplicity”.
Headquartered in the Netherlands, Philips employs 119,000 employees in more than 60 countries worldwide. With sales of EUR 25.4 billion
in 2010, the company is a market leader in cardiac care, acute care and home healthcare, energy efficient lighting solutions and new
lighting applications, as well as lifestyle products for personal well-being and pleasure with strong leadership positions in flat TV, male
shaving and grooming, portable entertainment and oral healthcare. News from Philips is located at www.philips.com/newscenter.
GE Healthcare's Performance Solutions business partners with hospitals and health systems across the globe to help improve their
overall performance. The business provides knowledge solutions to reduce unnecessary waste - which comes in three forms (1)
underutilization of resources (2) unintended clinical variation (3) and fragmented care delivery - and create safer more efficient patient
care. Performance Solutions leverages GE's operational improvement tools and advisory capabilities with GE Healthcare's clinical and
technological capabilities, providing a unique combination of advisory, technology and healthcare expertise. The business splits its
global headquarters between Barrington, United States and Buc, France.
Visit www.gehealthcare.com to learn more.
Signium International truly is a global executive search firm.
With more than 40 offices spread across nearly 30 countries, Signium International’s network of search consultants offers local healthcare
market knowledge with a global reach. Our consultants cover the globe like no other firm. When you choose Signium International to search for
your next CEO, CFO, or any other senior management member, you’ll find we are able to recruit from all over the world, while being mindful of
the specific needs of your organization, community and patients.
Our consultants actively engage and advise throughout the entire search process – we’re there from the initial site visit all the way through the
first months of the winning candidate accepting the position. Signium International is effective in finding the right executive quickly and
efficiently because we collaborate easily with our colleagues around the world. Having local knowledge of the healthcare market, culture and
business practices of your country can’t be substituted with having solely a large team of consultants in the United States. With offices
throughout the Americas, Europe, Middle East, Africa, and Asia Pacific, we are confident we can best serve your needs.
With more than six decades of experience, Signium International’s consultants have an in-depth understanding of the various facets of the
healthcare industry: integrated healthcare systems and hospital systems; hospitals (independent, community, academic, government,
nonprofit, for-profit, start-up, etc.); physician practice groups; medical schools; medical associations; boards; and more.
For more information, please contact: Email: ltyler@signium.com
World Hospitals and Health Services Vol. 47 No. 3 49

IHF corporate partners
VEOLIA ENERGY NORTH AMERICA is a leading U.S. developer and operator of sustainable energy systems. Veolia Energy provides
sustainable energy services, and facility operations and management to nearly 5,550 healthcare institutions in 42 countries around the
world, representing almost 500,000 beds.
Veolia Energy delivers solutions that enhance the economic, technical and environmental performance of complex systems and
equipment within a hospital: energy supply, including on-site power generation for critical areas such as operating rooms, neonatology, and
research and testing laboratories; steam for use in heating, sterilization, and service water heating; mechanical refrigeration facilities for
food service and morgues; and more basic services such as HVAC, heating and cooling systems. Partnering with Veolia Energy permits
hospitals to transfer their operating risks to a firm that specializes in preventive and predictive maintenance, energy optimization, and
carbon footprint reduction.
Veolia Energy North America is part of the Veolia Environnement companies in North America, employing more than 28,000 North
American personnel. Veolia Environnement (NYSE: VE and Paris Euronext: VIE), is the global standard for environmental services. With
approximately 313,000 employees in 74 countries who deliver sustainable environmental solutions in water management, waste services,
energy management, and passenger transportation, Veolia Environnement recorded annual revenues of nearly $50 billion in 2009. Veolia
Environnement is in the Dow Jones Sustainability World Index (DJSI World) and Dow Jones STOXX Sustainability Index (DJSI STOXX). Visit the
company's Web sites at www.veoliaenergyna.com and www.veolianorthamerica.com.
50 World Hospitals and Health Services Vol. 47 No. 3

Reference
IHF Governing Council 2009-2011
THE EXECUTIVE COMMITTEE
President
Dr JOSE CARLOS DE SOUZA
ABRAHAO
President
CONFEDERACAO NACIONAL
DE SAUDE (CNS)
SRTVIS Quadra 701,
Conjunto E
Edificio Palacio do Radio 1
Brasilia DF, CEP 70340-906
BRAZIL
President-Designate
Mr THOMAS C DOLAN
CEO
AMERICAN COLLEGE OF
HEALTHCARE EXECUTIVES
One North Franklin Street
Suite 1700
Chicago, Illinois 60606-
3491
UNITED STATES OF
AMERICA
Immediate Past Presidents
Dr IBRAHIM A AL
ABDULHADI
Assistant Undersecretary
for Health Insurance Affairs
MINISTRY OF HEALTH
State of Kuwait
PO Box 5, PIN Code 13001
KUWAIT
Mr GERARD VINCENT
Délégué Général
FEDERATION HOSPITALIERE
DE FRANCE
1 bis Rue Cabanis
75014 Paris
FRANCE
Treasurer
Dr LEKE PITAN
Former Commissioner for
Health – Lagos State
House G40C, Road 2
Victoria Garden City, Lagos
NIGERIA
Dr JUAN CARLOS LINARES
Director
CAMARA ARGENTINA DE EMPRESAS DE SALUD (CAES)
Tucuman 1668, 2 Piso
Buenos Aires C.P. 1050
ARGENTINA
Prof HELEN LAPSLEY
Research Professor
CENTRE OF NATIONAL RESEARCH ON DISABILITY &
REHABILITATION MEDICINE
University of Queensland
3 Keston Avenue
Mosman, Sydney NSW 2088
AUSTRALIA
Prof GUY DURANT
Administrateur général
CLINIQUES UNIVERSITAIRES SAINT-LUC
Avenue Hippocrate 10
B – 1200 Bruxelles
BELGIUM
Dr GEORG BAUM
Chief Executive
GERMAN HOSPITAL FEDERATION
Wegelystrasse 3
10623 Berlin
GERMANY
Dr LAWRENCE LAI
Senior Advisor
HONG KONG HOSPITAL AUTHORITY
Room 1003, Administration Block
Queen Mary Hospital
102 Pokfulam Road
HONG KONG (SAR)
Dr MUKI REKSOPRODJO
International Relations
INDONESIAN HOSPITAL ASSOCIATION (IHA) -
PERHIMPUNAN RUMAH SAKIT SELURUH INDONESIA
(PERSI)
c/o Jl.H.R.Rasuna Said Kav.C-21 Kuningan Jakarta
Selatan 12940 INDONESIA
Dr TSUNEO SAKAI
President
JAPAN HOSPITAL ASSOCIATION
13-3 Ichibancho, Chiyodaku, Tokyo
JAPAN
Dr TSUNEO SAKAI
President
JAPAN HOSPITAL ASSOCIATION
13-3 Ichibancho, Chiyodaku, Tokyo
JAPAN
DR DR KWANG TAE KIM
Past President
KOREAN HOSPITAL ASSOCIATION
35-1, Mapo-Dong, Mapo-Gu, Seoul
KOREA
Dr ERIK KREYBERG NORMANN
Senior Advisor
THE NORWEGIAN DIRECTORATE OF HEALTH
Universitetsgata 2
NO-0130 OSLO, NORWAY
Prof CARLOS PEREIRA ALVES
Vice Chair
ASSOCIACAO PORTUGUESA PARA O
DESENVOLVIMENTO HOSPITALAR
Av. António Augusto de Aguiar, 32-4º
1050-016 Lisboa
PORTUGAL
Dr THABO LEKALAKALA
Director - Hospital Management
and Planning
DEPARTMENT OF HEALTH
Street Hallmark Building
231 Proes Street
001 Pretoria
SOUTH AFRICA
Ms PAULINE DE VOS BOLAY
Membre de la Direction Générale
HUG – Hopitaux Universitaires de Genève
Avenue de Beau-Séjour 22
1211 Genève 14
SWITZERLAND
Dr DELON WU
President
TAIWAN HOSPITAL ASSOCIATION
25F, No29-5
Sec. 2, Jung jeng E. Road
Danshuei Township, Taipei County
TAIWAN
Mrs ALISON KANTARAMA
President
UGANDA NATIONAL ASSOCIATION OF HOSPITAL
ADMINISTRATORS (UNAHA)
Mulago Hospital
PO Box 7051, Kampala
UGANDA
Mr ABDUL SALAM AL-MADANI
President
INDEX HOLDING
Dubai Healthcare City
Block B, Offices 203 – 303
P.O.Box 13636, Dubai
UNITED ARAB EMIRATES
Mr MICHAEL FARRAR
Chief Executive
NHS CONFEDERATION
29, Bressenden Place
London SW1E 5DD
UNITED KINGDOM
World Hospitals and Health Services Vol. 47 No. 2 51

Reference
2011 Events
IHF
37th World Hospital Congress
8-10 November 2011, Dubai, United Arab Emirates
Theme: “Healthcare in a Changing World: Overcoming the Challenges”
Email: Sheila@ihf-fih.org; siddarth.nanthur@index.ae Website: http://www.ihfdubai.ae
MEMBERS
FRANCE
36ème Congrès de la FEHAP
October 5, 6 and 7, 2011, la Cité des Congrès de Lyon, Lyon
For more information: http://congres.fehap.fr/
SWITZERLAND
Congrès H+ 2011
3 November 2011, Hôtel Bellevue Palace, Berne
For more information: http://www.hplus.ch/fr/servicenav/evenements/congres_h/
2012
IHF
IHF Hospital and Healthcare Association Leadership Summit
May/June 2012 - South Africa
(By invitation only)
For more information, contact sheila@ihf-fih.org
MEMBERS
USA
Congress on Healthcare Leadership
19-22 March 2012, Hyatt Regency Chicago, Chicago, Illinois
For more information: http://ache.org/Congress
COLLABORATIVE
Geneva Health Forum – Fourth Edition
18-20 April 2012
A Critical Shift to Chronic Conditions: Learning from the Front liners
Geneva, Switzerland
For more information: http://www.ache.org/Congress http://ghf12.org / www.genevahealthforum.org
2013
IHF
38th World Hospital Congress
18-20 June, Oslo, Norway
Future Health Care: The Possibilities of new technology
For more information: http://oslo2013.no Email: Sheila@ihf-fih.org
52 World Hospitals and Health Services Vol. 47 No. 2

Who knew that space exploration would
lead us closer to the human heart?
We did.
We’re always exploring new ways to apply innovative technologies. By applying NASA technology
we were able to leverage an innovative polymer originally designed to survive challenges in space.
Its stability in extreme environments, corrosion-protective qualities and ability to
work in very small places allowed us to reach the complex left side of the heart, which
led to one giant leap in product design. We’re always reaching further, going farther.
The story continues at medtronic.com/innovation.
Innovating for life.
UC201102321 EN © 2010 Medtronic, Inc. All Rights Reserved

FUTURE HEALTH CARE
The possibilities of
new technology.
oslo2013.no